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Form Tt-19-Pm - Tobacco Product Manufacturer Certification For Participating Manufacturers Page 3

FORM TT-19-PM

Part 4: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer)

Under penalty of perjury, I state that (1) the Tobacco Product Manufacturer, as of the date of this Certification, is

a Participating Manufacturer in full compliance with all applicable sections of Va. Code §§ 3.1-336.3 through 3.1-

336.16; (2) I have examined this Certification, including attachments and supporting documents and, to the best

of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct

and complete; (3) I understand that the Tobacco Product Manufacturer is required to comply with state and

federal laws concerning the sale of tobacco products; (4) I understand that the Attorney General may require

additional information and/or documentation to determine if the Tobacco Product Manufacturer qualifies for listing

in the Virginia Tobacco Directory; and (4) I am a qualified company officer authorized to bind the Tobacco

Product Manufacturer making this Certification.

Name:

Title:

Phone:

Fax:

Email:

Date:

Signature:

Notary:

City/County of

Subscribed and sworn to before me on this date:

Signature:

My commission expires:

Mail this original fully executed Certification, including attachments and supporting documents to:

Tobacco Unit

Office of the Attorney General

900 East Main Street

Richmond, Virginia 23219

Mail a copy of the Certification to:

Tobacco Tax Unit

Virginia Department of Taxation

P.O. Box 715

Richmond, Virginia 23218-0715

Additional information is available at:

Rev. 02.01.05

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Form Tt-19-Pm - Tobacco Product Manufacturer Certification For Participating Manufacturers Page 3