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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