Form Cg-30 - Certification Of Tobacco Master Settlement Agreement Status - New York State Department Of Taxation And Finance

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CG-30
New York State Department of Taxation and Finance
Certification of Tobacco Master Settlement
(1/06)
Agreement Status
Tobacco product manufacturer identification
(type or print)
Legal name
Federal employer identification number (FEIN)
Mailing address
City or town
(number and street or PO box)
State or province
Country
ZIP Code
Telephone number
Fax number
Date business began in New York State
(include area code or country code)
(include area code or country code)
(month, day, year)
(
)
(
)
Check this box if this is an amended certification.
Check the applicable box (item 1 or item 2) to indicate that the entity is either a participating or non-participating manufacturer.
Certification
I certify that the above-named tobacco product manufacturer is:
1.
a participating manufacturer in the Tobacco Master Settlement Agreement as defined in Public Health Law section 1399-pp that has
generally performed its financial obligations under the Master Settlement Agreement; or
2.
a non-participating manufacturer (as defined in the Tobacco Master Settlement Agreement) in full compliance with the provisions of
Public Health Law section 1399-pp that has established any required qualified escrow fund.
I also certify that I have attached Form CG-30.1, Information Regarding Brands Sold in New York, listing all brands of cigarettes of the
above-named tobacco product manufacturer sold for consumption in New York State from January 1 of the previous calendar year until the
date of this certification.
If I checked box 2 above certifying that the tobacco product manufacturer is a non-participating manufacturer, I also certify that I have
attached to the copies of this certification which are sent to the Commissioner of Taxation and Finance and the Attorney General of New York
State, a copy of Form CG-30.2, Information Regarding Escrow Payment, covering the calendar year beginning January 1 prior to the year in
which this certification is made.
If this is an amended report, and if the tobacco product manufacturer is a non-participating manufacturer, I certify by checking box 2 above,
that I provided a copy of Form CG-30.2 for the calendar year 20
to the Commissioner of Taxation and Finance and the Attorney
General of New York State on
,
.
(month)
(day)
(year)
State of New York County of
Under penalty of perjury, I declare that the statements contained in this certification, including any accompanying statements or attachments,
are true, correct, and complete in every particular, and that I am a person authorized to bind the manufacturer making this certification either
under the laws of New York State or of the jurisdiction where the manufacturer resides or is organized. This certification is made to induce
New York State tax agents to affix New York State tax stamps pursuant to the Tax Law onto the cigarettes of the above-named tobacco
product manufacturer that are to be sold within New York State.
Authorized signature
Title
Printed name
Date
Subscribed and sworn to or affirmed before me this
day
of
20
Notary Public: New York State*
My commission expires:
Seal:
*if sworn or affirmed outside of New York State, please see instructions.

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