Tobacco Enforcement Unit

Forms

The documents below are fillable PDF forms. Users may input the required information by clicking on the appropriate line and typing the information (preferred method), or by printing and completing the form by hand.

 

Fire Standards Compliance Certification Forms for All Manufacturers

  • Fire Standards Compliance Certification Form
    Cigarette manufacturers must certify every three years to the Kansas State Fire Marshal that its designated cigarettes have undergone the required testing and have met the required performance standards set forth in K.S.A. 31-603. Use this form to submit all initial, supplemental and renewal certifications.

  • Tobacco Product Manufacturer Appointment of Agent for Service of Process Form
    Cigarette manufacturers submitting the Fire Standards Compliance Certification Form must appoint an agent for service of process in Kansas and identify the agent to the Kansas Secretary of State.

MSA Certification Forms for Non-Participating Manufacturers

  • Model Escrow Agreement (Microsoft Word Document)
    Non-Participating Manufacturers must establish a qualified escrow fund pursuant to K.S.A. 50-6a03(b). Use this Model Escrow Agreement in the execution of your escrow arrangement with a qualifying financial institution.
  • Non-Participating Manufacturer Certification Form
    Non-Participating Manufacturers must certify on or before April 30 of each year its NPM designation and its compliance with the MSA and K.S.A. 50-6a01 et seq. Use this form to submit all initial, supplemental and renewal certifications.  
  • United States Importer Declaration Form
    Non-Participating Manufacturers located outside of the United States must provide a declaration from each of its importers to the United States that such importer accepts joint and several liability with the NPM. Use this form in conjunction with the Non-Participating Manufacturer Certification Form.

  • Standard Waiver of Sovereign Immunity
    Non-Participating Manufacturers affiliated with a Native American Tribe must complete affirmatively waive tribal sovereign immunity. Use this form in conjunction with the Non-Participating Manufacturer Certification Form.

MSA Certification Forms for Participating Manufacturers

  • Participating Manufacturer Certification Form
    Participating Manufacturers must certify on or before April 30 of each year its PM designation and its compliance with the MSA and K.S.A. 50-6a01 et seq. Use this form to submit all initial, supplemental and renewal certifications. 

Other Forms 

  • Qualified Escrow Fund Assessment Form
    Financial institutions holding qualified escrow funds must provide certain financial information pursuant to K.S.A. 50-6a10(b). Use this form to provide proof of the amount of money held in each such fund.

  • Request to Receive Email Notification of Directory Updates
    Stampings agents, wholesale dealers and distributors may elect to receive email notifications of directory updates, including notice of removal of a manufacturer or brand family. Use this this form to submit your request.

Contact

Tobacco Enforcement Unit
120 SW 10th Ave., 2nd Floor
Topeka, KS 66612-1597 
tobacco@ag.ks.gov 
(785) 368-6289

Tobacco Enforcement

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