Form 1786 "South Dakota Tobacco Product Manufacturer Complementary Legislation Certification" - South Dakota

What Is Form 1786?

This is a legal form that was released by the South Dakota Department of Revenue - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 30, 2019;
  • The latest edition provided by the South Dakota Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1786 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Revenue.

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Download Form 1786 "South Dakota Tobacco Product Manufacturer Complementary Legislation Certification" - South Dakota

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SD EForm - 1783
V17
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA TOBACCO PRODUCT MANUFACTURER
COMPLEMENTARY LEGISLATION CERTIFICATION
Mail this completed Complementary Legislation Certification and attachments to:
Form is due:
South Dakota Department of Revenue
ATTN: Sally Staufer
April, 30, 2019
Special Tax
1302 E HWY 14 Suite 1
Pierre, SD 57501
Please Type or Print
Part 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION
A.
Complete company information below:
Company Name
Address
City/State/Zip
Telephone Number
Fax Number
E-Mail Address
Website
Name/Title of Person Completing Form
Address of Manufacturing Plant(s)
Name of Factory Manager(s)
Phone Number of Factory Manager(s)
Fax Number of Factory Manager(s)
If located in the US: Manufacturer’s Federal Taxpayer ID Number:
If located in the US: TTB Tobacco Manufacturer Permit Number:
B.
The tobacco product manufacturer identified above, as of the date of this Certification, is
(check one below):
A Participating Manufacturer [Complete parts 1, 2A and 9]
A Non-participating Manufacturer [Complete entire form except 2A]
This form is (check one below):
Initial Certification – Manufacturer is not currently listed on the South Dakota Tobacco Brand
Listing Annual Certification – Due April 30, 2019
Supplemental Certification – Change of information provided to the SD Department of Revenue
All manufacturers must update this Certification thirty calendar days prior to any addition to or
modification of the Brand Families sold in South Dakota.
1
SD EForm - 1783
V17
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA TOBACCO PRODUCT MANUFACTURER
COMPLEMENTARY LEGISLATION CERTIFICATION
Mail this completed Complementary Legislation Certification and attachments to:
Form is due:
South Dakota Department of Revenue
ATTN: Sally Staufer
April, 30, 2019
Special Tax
1302 E HWY 14 Suite 1
Pierre, SD 57501
Please Type or Print
Part 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION
A.
Complete company information below:
Company Name
Address
City/State/Zip
Telephone Number
Fax Number
E-Mail Address
Website
Name/Title of Person Completing Form
Address of Manufacturing Plant(s)
Name of Factory Manager(s)
Phone Number of Factory Manager(s)
Fax Number of Factory Manager(s)
If located in the US: Manufacturer’s Federal Taxpayer ID Number:
If located in the US: TTB Tobacco Manufacturer Permit Number:
B.
The tobacco product manufacturer identified above, as of the date of this Certification, is
(check one below):
A Participating Manufacturer [Complete parts 1, 2A and 9]
A Non-participating Manufacturer [Complete entire form except 2A]
This form is (check one below):
Initial Certification – Manufacturer is not currently listed on the South Dakota Tobacco Brand
Listing Annual Certification – Due April 30, 2019
Supplemental Certification – Change of information provided to the SD Department of Revenue
All manufacturers must update this Certification thirty calendar days prior to any addition to or
modification of the Brand Families sold in South Dakota.
1
PART 2: BRAND FAMILY IDENTIFICATION (attach additional sheets if necessary)
A.
Participating Manufacturer:
The Participating Manufacturer identified in Part 1 has the following brand families, each of which the manufacturer
hereby affirms are to be deemed its cigarettes for the purposes of calculating its payments under the Master Settlement
Agreement, in the volume and shares determined pursuant to the Master Settlement Agreement:
Indicate with an asterisk (*) those brands that will not be sold in South Dakota as of the date of this
certification. (Attach additional sheet if necessary).
NOTE: The South Dakota Department of Revenue retains the discretion to determine that the cigarettes in a
brand family constitute cigarettes of another tobacco product manufacturer pursuant to SDCL 10-50-75.
Brand Family Name
Cigarettes or Roll-Your-Own
Brand Family Name
Cigarettes or Roll-Your-Own
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
I.
Are you requesting that all brand families above be listed on South Dakota’s directory?
Yes ____ No _____
NOTE: If the answer is “No,” then identify the brand families that you are not requesting to be listed:
II.
For each of the above brand families (cigarettes only) provide a copy of the current Federal Trade
Commission (FTC) approval letter for health-warning rotation plan. Additional information can be
obtained at:
Federal Trade Commission
600 Pennsylvania Avenue, N.W.
Washington, D.C. 20580
General Information Locator: (202) 326-2222
http://www.ftc.gov
III.
For each of the above brand families (cigarettes only) provide a copy of the current Center for Disease
Control (CDC) ingredient listing compliance letter(s) and a statement as to which brand’s ingredients were
submitted for each approval letter. Additional information can be obtained at:
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Telephone: 1-800-311-3435
http://www.cdc.gov/netinfo.htm
2
B.
Non-participating Manufacturer:
The Non-participating Manufacturer identified in Part 1 has the following brand families, each of which the tobacco product
manufacturer affirms are to be deemed its cigarettes for purposes of SDCL ch. 10-50B:
List all brand families sold in the preceding calendar year and at any time in the current calendar year.
Indicate by an asterisk (*) any brand no longer being sold in South Dakota as of the date of this
certification.
.09 oz. of RYO constitutes one unit. Attach additional sheets if necessary.
NOTE: The South Dakota Department of Revenue retains the discretion to determine that the cigarettes in a
brand family constitute cigarettes of another tobacco product manufacturer pursuant to SDCL 10-50-75.
Units sold in
South Dakota in 2017
Previous Manufacturer
Brand Family Name
Cigarettes or Roll-Your-Own
and to date in 2018,
(Name & Address)
identified separately
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
Cigarettes
RYO
I.
Are you requesting that all brand families above be listed on South Dakota’s directory?
Yes ____ No _____
NOTE: If the answer is “No,” then identify the brand families that you are not requesting to be listed:
II.
Provide a sample of the current packaging of each brand within each brand family.
Check here if previously supplied packaging samples have not changed.
NOTE: If the manufacturer has previously supplied such packaging to the SD Department of Revenue and if such
packaging has not changed, samples need not be supplied this year.
III.
If located in the United States, provide a copy of the latest TTB Tobacco Manufacturer Permit.
IV.
For each of the above brand families (cigarettes only) provide a copy of the current Federal Trade
Commission (FTC) approval letter for health-warning rotation plan. Additional information can be
obtained at:
Federal Trade Commission
600 Pennsylvania Avenue, N.W.
Washington, D.C. 20580
General Information Locator: (202) 326-2222
http://www.ftc.gov
3
V.
For each of the above brand families (cigarettes only) provide a copy of the current Center for Disease
Control (CDC) ingredient listing compliance letter(s) and a statement as to which brand’s ingredients were
submitted for each approval letter. Additional information can be obtained at:
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Telephone: 1-800-311-3435
http://www.cdc.gov/netinfo.htm
VI.
Are any cigarette brand families listed above or brands within a brand family listed above manufactured
(fabricated) by an entity other than the applicant listed in Part 1A? Yes _____ No _____
NOTE: If the answer is “Yes,” then identify the brand(s) and the manufacturer by plant street address, contact person,
telephone and facsimile numbers, and e-mail. In addition, explain the relationship between the manufacturer (fabricator)
and applicant. Attach copies of all agreements or contracts between the manufacturer (fabricator) and the applicant.
Attach additional sheets if necessary.
VII.
Are any RYO brand families listed above or brands within a brand family listed above packaged or
labeled by an entity other than the applicant listed in Part 1A or packaged or labeled by applicant on behalf of
another entity? Yes _____ No _____
NOTE: If the answer is “Yes,” then identify the brand(s) and the other entity by street address, contact person, telephone
and facsimile numbers, and e-mail. In addition, explain the relationship between the other entity and applicant. Attach
copies of all agreements or contracts between the manufacturer and the applicant. Attach additional sheets if necessary.
4
PART 3: NON-PARTICIPATING MANUFACTURER MARKETING AND DISTRIBUTION INFORMATION
Complete for all distributors, wholesalers, and retailers* selling manufacturer’s product(s) into South Dakota to
which the Non-participating Manufacturer identified in Part 1 has sold cigarettes and/or RYO tobacco. Attach
additional sheets if necessary.
*UNDER SOUTH DAKOTA LAW, ONLY LICENSED DISTRIBUTORS OR LICENSED WHOLESALERS MAY SELL
CIGARETTES OR RYO TOBACCO TO RETAILERS.
Name
Address and Phone
Identify whether a
Brand
Number
Distributor, Wholesaler, or
Retailer
PART 4: NON-PARTICIPATING MANUFACTURER TRADEMARK INFORMATION
Provide documentation of the trademark holder of each brand family. If trademark holder is different than
applicant, then provide an explanation of the relationship between the two entities. Attach additional sheets if
necessary.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PART 5: NON-PARTICIPATING MANUFACTURER ORGANIZATION INFORMATION
If applicant is a:
Attach to certification
Partnership or association
Current copy of articles, if any, OR the certificate
required to be filed by any state, county, municipality,
or tribal entity.
Corporation
1. Current copy of corporate charter OR certificate of
corporate existence or incorporation.
2. Extracts of stockholders’ meetings, bylaws,
directors’ meetings or other documents that show that
person signing this certification has authority to act on
behalf of the corporation.
Limited liability company or other business
Current copy of the business documents filed with the
organization
state, county, municipality, or tribal entity when such
filing is required. A limited liability company must
provide an accurate copy of its operating agreement.
5