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

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Part 4: Fabricator Identification (check one)

□

The Tobacco Product Manufacturer fabricates its own cigarettes.

□

Tobacco Product Manufacturer uses a fabricating facility that is separate from the

Manufacturer itself.

If the Tobacco Product Manufacturer uses a fabricating facility that is separate from the Tobacco

Product Manufacturer itself, provide the following information:

Fabricating Facility Name(s) if different from Tobacco Product Manufacturer:

Physical Address:

Mailing Address:

Fabricating Plant Phone:

Contact:

Title:

Phone:

Email:

Fax:

Website:

• A photograph or diagram of the Tobacco Manufacturer’s fabricating facility must be attached to

the Certification. Identify in the diagram where the equipment and facilities for manufacturing

the Brand Family(s) are located.

• A list of every Brand Family the Tobacco Manufacturer has fabricated, or caused to be

fabricated by another entity since July 1, 1999 must be attached to the Certification. Indicate

with an asterisk (*) any Brand Family not being sold in the current year, and identify whether

such Brand Family is still being manufactured and by what entity.

Part 5: Disclosure of Enforcement Actions and Prior Determinations (check any that may be

applicable)

□

The Tobacco Product Manufacturer (or any person or entity listed in the Certification) has had

any of its cigarettes banned or enjoined from sale by any state or federal court or administrative

agency.

• If the above is applicable, for each such enforcement action a copy of any case decision

and the following information must be attached to the Certification: (1) the Brand Family(s)

banned and/or enjoined; (2) the governmental entity (federal, state, local or foreign) or official

bringing the action; (3) the case number; and, (4) the name and address of the government

attorney or official that brought the action.

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