State of Illinois Certification of Non-Participating Manufacturer Manufacturer Identification NPM-1 Accounts Addendum (Attach addendum pages to NPM-1 Certification Form.) Company Name Accounts Addendum Page ____ of ____ Part 7: Certification of Deposits, Withdrawals and Transfers Prepare separate page for each sub-account. The NPM certifies the following to be a complete record of each deposit and withdrawal or transfer which has occurred from any and all accounts containing funds held for the benefit of the State of Illinois. Report ending balances of all such accounts, even where no deposits or withdrawals occurred. Attach copies of records of the financial institution documenting any account activity. Illinois Sub-Account Number Name of Financial Institution (Escrow Agent) Deposit Amount Withdrawal or Transfer Amount Deposits Date Withdrawals/Transfers Ending Balance for this Illinois Sub-Account $ $ Explanation for Withdrawal or Transfer Column Totals $ Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com