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Form BOE-400-LME Fillable Certification for Manufacturer/Importer Cigarette License
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(1)Five times the retail value of the seized cigarettes or tobacco products defined as cigarettes under this section (1)The name address and telephone number of the manufacturer/importer (2)The license number of the manufacturer/importer as provided by the BOE (3)The name address and license number of the person to whom cigarettes or tobacco products are sold (4)An itemized listing of the cigarettes or tobacco products sold (a)Each invoice for the sale of cigarettes or tobacco products shall be legible (a)In the case of the first offense the BOE may revoke or suspend the license or licenses of the manufacturer or importer pursuant to the (b)Failure to comply with this section shall be a misdemeanor subject to penalties and fines pursuant to California Business and (b)In the case of a second or any subsequent offense in addition to the action authorized under subdivision (a) the BOE may impose a civil (City of) (CLEAR) CLEAR (Commission Expires) (Date) (Date) (Date) (Date) (Date) (DATE) (EMAIL ADDRESS) (eREG ID#) (Initial) (Initial) (Initial) (Initial) (Initial) (NAME (typed or printed) (Phone number) (PRINT) PRINT (TITLE) 1 All of the information contained in the completed Application and Schedule of Cigarette Brand Family Names is current true and correct 104557 inclusive of the Health and Safety Code or Part 13 (commencing with section 30001) of Division 2 of the Revenue and Taxation 2 If the applicant is a "tobacco product manufacturer" as defined in subdivision (i) of section 104556 of the Health and Safety Code the 3 Applicant consents to jurisdiction of the California courts for the purpose of enforcement of the California Cigarette and Tobacco Products 4 Applicant certifies that all packages of cigarettes it manufactures or imports and distributes in this state fully comply with subdivision (b) of 5 Applicant certifies that it will maintain purchase records sales records and any other records required by the BOE for one year at the 6 Applicant certifies that it shall include the following information on each invoice for the sale for distribution wholesale or retail sale of 7 Applicant understands and acknowledges that under California Business and Professions Code section 22980 1 no manufacturer shall 8 Applicant understands and acknowledges that under California Business and Professions Code section 22979 7 in addition to any other 9 Business and Professions Code section 22979(a)(4) requires an applicant to waive any sovereign immunity defense that may apply to any A "participating manufacturer" as defined in subsection II(jj) of the "Master Settlement Agreement" (MSA) or and Tobacco Products Licensing Act of 2003 the BOE may take the following actions: applicant certifies it is one of the following (check appropriate box): attorney must be attached to this application authorization signed by all general partners; for a corporation attach a corporate resolution; for an LLC attach the articles of incorporation BOARD OF EQUALIZATION BOE 400 LME (S1B) REV 1 (5 12) BOE 400 LME (S1F) REV 1 (5 12)STATE OF CALIFORNIA CA 94279 0088 California Office of the Attorney General CERTIFICATION CERTIFICATION FOR MANUFACTURER/IMPORTER CIGARETTE LICENSE CERTIFICATION FOR MANUFACTURER/IMPORTER CIGARETTE LICENSE (continued) cigarettes pursuant to California Business and Professions Code section 22979 6 City of: civil or criminal penalty provided by law upon finding that a manufacturer or importer has violated any provision of the California Cigarette Code and regulations adopted thereto In lieu of such a waiver the applicant may file a surety bond for a specified amount with the AG To COMMISSION EXPIRES Complete this form and mail it to the Board of Equalization Special Taxes and Fees P O Box 942879 Sacramento Date: Date: Date: Date: Date: download and file the applicable waiver of sovereign immunity forms or surety bond visit the AG website at EMAIL ADDRESS enforcement action brought by the California Office of the Attorney General (AG) or the BOE to enforce this division sections 104555 to eREG ID# fine of not more than five thousand dollars ($5 000) or both the imprisonment and the fine fully comply with all requirements of the federal Cigarette Labeling and Advertising Act (15 U S C sec 13355a et seq ) for the reporting of I certify that all the information provided in this application is true and accurate and I understand that any person who asserts the truth of any ingredients added to cigarettes Initial: Initial: Initial: Initial: Initial: Is in full compliance with paragraph (2) of subdivision (a) of section 104557 of the Health and Safety Code Licensing Act of 2003 and has appointed a registered agent for service of process and identified the registered agent to the BOE and the material matter that he or she knows to be false is guilty of a misdemeanor punishable by imprisonment of up to one year in the county jail or a NAME (typed or printed) Note: This document must also be signed and dated in front of an authorized notary public who also signs as a witness On behalf of the above manufacturer or importer the undersigned certifies the following: or(2)Five thousand dollars ($5 000) penalty in an amount not to exceed the greater of: Please acknowledge you have read and understand the sovereign immunity waiver requirements: premises identified in the license and make the records available for inspection by the BOE or a law enforcement agency for four years as procedures applicable to the revocation of a license set forth in section 30148 of the Revenue and Taxation Code Professions Code section 22981 required in California Business and Professions Code sections 22979 4 and 22979 5 Failure of a manufacturer/importer to comply with revoked Failure to comply with this section shall be a misdemeanor subject to penalties and fines pursuant to California Business and section 30163 of the Revenue and Taxation Code and that the cigarettes contained in those packages are the subject of filed reports that sell cigarettes to a distributor wholesaler importer or any other person who is not licensed or whose license has been suspended or SIGNATURE SIGNATURE OF NOTARY PUBLIC Subscribed and sworn to before me on this date: TELEPHONE NUMBER these sections shall be a misdemeanor subject to penalties and fines pursuant to California Business and Professions Code section 22981 This form must be signed by a corporate officer LLC member or manager or an authorized agent or partner For a partnership attach an TITLE which authorized the individual who signs below to certify this application If signed by an authorized agent a properly completed power of www oag ca gov/tobacco/directory/forms Waiver of sovereign immunity forms must be filed and submitted with this application