Please provide the completed notarized affidavit located below stating all certifying brands/styles are current and in compliance with FDA rules and regulations.
View/Download Notarized Affidavit
For any newly added brand style(s) please provide documentation to establish the style(s) in compliance with the Family Smoking Prevention and Tobacco Control Act, and
therefore able to be sold legally in the United States.
Should a brand style be determined to be Non-Substantially Equivalent throughout the course of the year, you are required to provide information as soon as it is made available to ensure that products on the Directory remain legal for sale.
List all states which you (the manufacturer), your importer, or any other entity shipped unstamped cigarettes or RYO tobacco into during the prior quarter. Also, include the business and address where the unstamped cigarettes or RYO tobacco were sent and total quantities shipped. Attach additional sheets if necessary.
If you were not the only manufacturer of any of your brand families or styles who shipped into the United States during the prior quarter, on a separate sheet provide the name and address of every other manufacturer and the dates of manufacturer by each manufacturer for each brand family or style.
Once an escrow agreement has been approved you cannot change it without prior approval of this Office. This includes a change in financial institution, including through a buyout or merger. This Office reserves the right to require a new escrow agreement. We also, reserve the right to reject any revisions which have not been approved in advance. Please verify that your financial institution is submitting copies of your escrow statements to our office.
I understand that any violation of the requirements of the Tobacco Product Manufacturer Directory
Act of the Tobacco Settlement Agreement Act of 2000 is a basis for removal of the manufacturer’s
brand families from the Commonwealth’s Directory of Approved Brands.
I agree that all packaging images submitted with this certification are free of proprietary and
confidential information and may be publicly posted on the Pennsylvania Tobacco Product Directory
I hereby certify, under penalty of perjury, that the Tobacco Product Manufacturer identified in Part
I is a Non-Participating Manufacturer in full compliance with the Tobacco Settlement Agreement
Act, that is a resident of the Commonwealth, or has appointed a registered agent for service of
process, that has established and continuously maintains a qualified escrow fund, and that has
executed a qualified escrow agreement approved by the Attorney General.
I hereby certify under penalty of perjury that the brand families submitted for inclusion on the
Pennsylvania Tobacco Product Directory of Approved Brands are legal to sell in the United States
under the Family Smoking Prevention and Tobacco Control Act and all regulations promulgated
thereunder and therefore have been approved/certified by the FDA and/or are currently under
review by the FDA. If a brand family style has been issued a Non-Substantially Equivalent Order
or any other determination by the FDA making the product no longer able to be sold in the US, we
will notify the Office of Attorney General immediately.
I hereby certify under penalty of perjury that I will continually provide updated information
throughout the year regarding any and all updated documentation to ensure the products
contained on the Pennsylvania Tobacco Product Directory of Approved Brands are able to be legally
I hereby certify and declare under penalty of perjury that all of the statements and information
contained in the certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct and complete and that I am a person authorized to bind the Tobacco Product Manufacturer making this certification either under the laws of the Commonwealth of Pennsylvania or of the jurisdiction where the manufacturer resides or is
I affirm under penalty of perjury that the brand families included in this certification are the cigarettes of the undersigned TPM, who takes responsibility either for purposes of calculating payment under the MSA for the relevant year in volume and share determined under the MSA OR purposes of calculating payment of escrow into a qualified escrow account as required under the TSAA.