Form 55b - Tobacco Product Manufacturer'S Certification - 2017 Page 3
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10State of Nebraska
Certification Year
2017
Tobacco Product Manufacturer’s
Certification, Form 55B
For Official Use Only
RESET FORM
This form is (check one below):
c
Initial Certification — Tobacco Product Manufacturer is not currently listed on the Nebraska Directory of Certified
Tobacco Product Manufacturers and Brands (Directory).
c
Annual Certification — Due April 30th of each year.
c
Supplemental Certification — Change in brands, registered agent, or other information.
Note: All tobacco product manufacturers must file a Supplemental Certification 30 calendar days prior to any
addition, removal, or modification of the brand families on the Directory.
Part 1: Tobacco Product Manufacturer Identification
A. Business Information (please type or print):
Business Name
Physical Address
Mailing Address
City/State/Country/Zip Code
County
Phone Number, Including Area Code
Fax Number
Email Address
Name/Title of Person Completing Report
If located in the U.S., Manufacturer’s Federal Taxpayer ID Number:
If located in the U.S., attach a copy of your TTB Tobacco Manufacturer’s Permit and provide the permit number and expiration date below.
Permit Number _________________________ Expiration Date _________________________
B. The Tobacco Product Manufacturer Identified in Part 1A, as of the Date of This Certification, is a (check
one below):
c
Participating manufacturer, as defined in the Master Settlement Agreement (MSA), generally performing its
financial obligations as required by Neb. Rev. Stat. § 69-2703(1)(Cum. Supp. 2016). Complete Parts 1, 2A, 2C-E, 3,
and 9.
c
Nonparticipating manufacturer in full compliance with the escrow requirements of Neb. Rev. Stat. § 69-2703(2)(a)
(Cum. Supp. 2016). Complete entire form, except Part 2A.
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