IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 1 of 11 (revised 12/18/2018) OFFICE OF THE ATTORNEY GENERAL Lawrence G. Wasden Consumer Protection Division 954 W. Jefferson, 2nd Floor P.O. Box 83720 Boise, ID 83720-0010 Phone: (208) 334-2424 IDAHO NON-PARTICIPATING MANUFACTURER Certification of Compliance PART 1: TYPE OF CERTIFICATION AND SALES YEAR A. Type of Certification: B. Sales Year: Initial Annual Supplemental 2018 Other Year: PART 2: NON-PARTICIPATING MANUFACTURER (HEREAFTER NPM APPLICANT), IDENTIFICATION, STATUS, AND PERMITS/LICENSES A. NPM Applicant Identification: Company Name: Physical Address: (street address only; no post office box): Mailing Address (if different from above): Phone: FAX: Email Address: Website Address: FEIN: Name of Person Completing Certification: Title: For Office Use Only American LegalNet, Inc. www.FormsWorkFlow.com IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 2 of 11 (revised 12/18/2018) 1. NPM Applicant222s Officers and Owners: List NPM Applicant222s officers and owners (all persons with an equity interest of 10% or more in the company). Check Correct Box President Partner Other Vice Pres. Partner Other Secretary Partner Other Name Street Address Telephone and Facsimile Numbers E-mail address Attach additional sheets of paper as needed to provide a complete response. 2. NPM Applicant222s Corporate or Business Documents: Current copies of articles of incorporation, corporate charters, certificates of corporate existence, operating agreements, and bylaws or extracts of stockholders222 meetings, as applicable to corporate status, are attached. Yes No B. NPM Applicant222s Status: The NPM Applicant certifies that as of the date of signing this Certification, it is (answer each section): 1. In full compliance with Idaho Code 247 39-7801 et seq. and Idaho Code 247 39-8401 et seq., including all quarterly escrow deposits required by Rule 100, 101, and 102 of the Idaho Rules Implementing the Idaho Tobacco Master Settlement Agreement Complementary Act, codified at IDAPA 04.20.01100 226 102. Yes No If no was initialed, set forth on separate sheets of paper the reason(s) the NPM Applicant is not in compliance. 2. The manufacturer of the Brand Families listed in this Certification and that these Brand Families are intended to be sold in the United States, including Cigarettes intended to be sold in the United States through an importer. Yes No If no was initialed, set forth on separate sheets of paper the name and address of the manufacturer of the Brand Family(ies) and state fully the basis for seeking to have the Brand Family(ies) certified by the NPM Applicant. Include an explanation of how the NPM Applicant qualifies as a Tobacco Product Manufacturer of the Cigarettes. Provide documentation to support your claim. Include in such explanation and documentation the location of American LegalNet, Inc. www.FormsWorkFlow.com IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 3 of 11 (revised 12/18/2018) the transfer of ownership of the Cigarettes and copies of every agreement between the NPM Applicant and the manufacturer. 3. The first purchaser anywhere for resale in the United States of Cigarettes that the Cigarette222s manufacturer did not intend to be sold in the United States? Yes No If yes was initialed, set forth on separate sheets of paper the name and address of the Cigarette222s manufacturer. Explain upon what grounds the manufacturer did not intend for its Cigarettes to be sold in the United States. Provide documentation to support your claim. Include in such explanation and documentation the location of the transfer of ownership of the Cigarettes and copies of every agreement between the NPM Applicant and the manufacturer. 4. The successor of any entity described in Idaho Code 247 39-7802(i)(1) or (2)? Yes No If yes was initialed, set forth on separate sheets of paper the name of the entity for which you certify the NPM Applicant is the successor, its mailing address, contact person, and telephone and facsimile numbers. C. NPM Applicant222s Licenses/Permits: 1. Attach a copy of the NPM Applicant222s current U.S. Treasury, Tobacco Tax Bureau (TTB) permit(s) as a manufacturer and/or as an importer. 2. If the NPM Applicant is located in a country other than the United States, provide copies of any manufacturing or importer licenses, certificates, permits or similar documents issued by the country where the manufacturing takes place. 3. If the NPM Applicant is located in a country other than the United States and the Cigarettes bear a United States trademark, provide a copy of the trademark holder222s certificate under penalty of perjury that it has not withdrawn consent to import the Cigarettes into the United States as required by 19 U.S.C. 2471681a (c)(3)(A), and a copy of the importer222s certificate under penalty of perjury that the trademark owner has not withdrawn consent to import the Cigarettes into the United States as required by 19 U.S.C. 2471681a (c)(3)(B). American LegalNet, Inc. www.FormsWorkFlow.com IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 4 of 11 (revised 12/18/2018) PART 3: BRAND FAMILY IDENTIFICATION A. Brand Families NPM Applicant Seeks to Certify: 1. Brand Family (Indicate with an asterisk (*) if no longer sold in Idaho) 2. Name and address of Tobacco Product Manufacturer of Brand Family in 2018 if different from NPM Applicant 3. For each Brand Family listed, name of trademark holder, the contact person of the trademark holder, and the contact person222s mailing address and telephone number Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco American LegalNet, Inc. www.FormsWorkFlow.com IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 5 of 11 (revised 12/18/2018) 1. Brand Family (Indicate with an asterisk (*) if no longer sold in Idaho) 2. Name and address of Tobacco Product Manufacturer of Brand Family in 2018 if different from NPM Applicant 3. For each Brand Family listed, name of trademark holder, the contact person of the trademark holder, and the contact person222s mailing address and telephone number Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Attach additional sheets as necessary. B. NPM Applicant222s Manufacturing History: 1. Provide a complete list of Cigarettes and Other Tobacco Products (e.g., RYO, cigars, pipe tobacco, smokeless tobacco, etc.) that the NPM Applicant has manufactured or imported, no matter where sold, including: a. Brand Family name; b. The date manufacturing first commenced or is intended to commence for each Brand Family; c. Time periods for manufacture of each Brand Family; d. The place of manufacture of each Brand Family, including name, physical address and factory contact; e. A list of prior manufacturers, if any, of each Brand Family; f. The trademark holder of each Brand Family. 2. Provide a list of States that have certified the NPM Applicant and the Brand Families NPM Applicant seeks to certify. If any State has refused to list or removed the NPM Applicant or a Brand Family of the NPM Applicant from that State222s directory, identify the State(s). American LegalNet, Inc. www.FormsWorkFlow.com IDAHO NON-PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 6 of 11 (revised 12/18/2018) C. Packaging Samples (check one): Initial certification: Samples of the actual packaging and labeling for each Brand Family (without tobacco) the NPM Applicant seeks to certify are attached. Annual certification227no new packaging: Samples of the actual packaging and labeling for each Brand Family the NPM Applicant seeks to certify in the current year have been previously provided and is current, in effect, and operative. Annual certification227new packaging: Changes in the packaging or labeling have occurred for one or more of the Brand Families the NPM Applicant seeks to c