StateofIllinoisCertificationofNon-ParticipatingManufacturerPleaseReviewInstructionsPriortoCompletion.NPM-1p.1of4 Part1:LiabilityYearandTypeofCertification LiabilityYearforthisCertification:Completeaseparateformforeachliabilityyearforwhichyouarecertifying.(checkone)2018Other: TypeofCertification:(checkone)InitialAnnualSupplemental Part2:ManufacturerIdentification CompanyNameFEIN MailingAddress CityStateZipCodeCountry PhoneFaxWebAddress Nameandtitleofpersoncompletingthisform Part3:BrandFamilyCertification(AttachBrandsAddendumpagesasnecessary) Theundersignedmanufacturercertifies,underpenaltyofperjury,asofthedateofthiscertification,itisaNon-ParticipatingManufacturer(NPM)andisinfullcompliancewiththeEscrowActandtheEscrowEnforcementActof2003aswellasanyregulationsandquarterlyinstallmentpayments.TheundersignedNPMcertifiesthatthefollowinglistisacompletelistofallofitsbrandfamilieswhicharetobedeemedtobeitscigarettes(includingRYOproduct)forpurposesofSection15oftheEscrowAct.NothinginthiscertificationshalllimitorotherwiseaffecttheState222srighttomaintainthatabrandfamilyconstitutescigarettesorroll-your-owntobaccoofadifferenttobaccoproductmanufacturerforpurposesofSection15oftheEscrowAct.ForeachbrandstylethattheFireMarshalhasapprovedandforwhichtheAttorneyGeneral222sOfficehasapprovedtheBrandFamily,providethefollowinginformation:BrandStyle,Size(100orKings),Flavor,Filter(y/n)andPackage(Soft/Box)asitshouldbelistedontheIllinoisDirectory.Providecorrections,ifany,forthebrandstyleinformationforFSCcigaretteslistedontheIllinoisDirectory.Includewithyourcertificationsamplepackagingforeachbrandfamilynamed.PackagingforFSCproductsmu stbeprovidedwhenchangesaremadetothepackagingornewproductsarecertifiedforlistingandsaleinIllinois. PackagingprovidedforcigarettesmustreflectcompliancewiththeCigaretteFireSafetyStandardAct(425ILCS2478/1,etseq.).Submitnewpackagingeachtimeyouchangeyourpackagingoraddnewbrandfamilies. BrandFamilyAsterisk(*)denotesbrandswhicharenolongersoldinIllinoisCheckOneReportUnitsSoldinSticksforCigarettesandinOuncesforRYOCheckindicatesPackaging is SubmittedName&addressofmanufacturerofbrandfamilyin2017ifdifferentfromNPMidentifiedinPart2 UnitsSoldin2018UnitsSoldin2019 CigaretteRYO CigaretteRYO CigaretteRYO CigaretteRYO CigaretteRYO TotalofRYOOunces TotalofCigaretteSticks American LegalNet, Inc. www.FormsWorkFlow.com StateofIllinoisCertificationofNon-ParticipatingManufacturerPleaseReviewInstructionsPriortoCompletion.NPM-1 p.2of4 Part4:CertificationofEscrowAccountandAgreement TheNPMcertifiesthatithasestablished,andcontinuestomaintain,afullyfunded,qualifiedescrowaccount,pursuanttoSection15oftheEscrowAct. NameofFinancialInstitution(EscrowAgent) MailingAddress CityStateZipCode PhoneFax ContactPersonContactE-Mail EscrowAccountNumberTotalamountheldinthisaccountfortheStateofIllinois IllinoisSub-AccountNumber$ ArefundsheldforthebenefitoftheStateofIllinoisinanyaccountotherthanthatlistedabove?YesNo Ifyouanswered223yes,224writethetotalamountofallfundswhicharebeingheldinanyaccountforthebenefitoftheStateofIllinois,includingtheamountlistedabove. $ HastheQualifiedEscrowAgreementbeenapprovedbytheAttorneyGeneral?AttachanexecutedcopyofyourcurrentescrowagreementwhetherornotithasalreadybeenapprovedbytheAttorneyGeneral.YesNoDateofAgreement:ApprovalDate: Part5:WorksheetforCigarettesSoldDuringLiabilityYear TotalofRYOOuncesfromPart3RefertoWorksheetatlefttocalculatethenumberofindividualcigarettesbearingIllinoiscigarettetaxstamps,includingroll-your-owntobacco(.09ounces=1cigarette),whichweremanufacturedbythismanufacturerandsoldinIllinoisduringthisreportingperiod.LiabilityYearWorksheetisfor: RYOStickCalculation(DivideRYOOuncesby.09) TotalofCigaretteSticksfromPart32018Other: TotalNPMSales(AddRYOStickCalculationtoTotalofCigaretteSticks)Pleaseconvertpoundstoouncesbeforeusingthisworksheet.(Multiplyby16.) Part6:DepositAmountUsetherateslistedbelowtofiguretheappropriatedepositamount. Fortheliabilityyear2007andlater,theratepercigaretteis............0188482ContacttheTobaccoEnforcementBureauforratesforpreviousyears. 1Entertheappropriateratefortheliabilityyear.10.0188482 2MultiplyLine1byTotalNPMSales(Part5)andwritetheamount.2 3MultiplyLine2bytheinflationadjustmentpercentageandwritetheamount.3 For2018liabilityperiod,theinflationadjustmentpercentageis.percent(multiplierof.). 4EnterthetotalamounttobepaidintotheescrowaccountforthisliabilityyearbythemanufactureridentifiedinPart2(thetotalofLines2and3).4$ 5Enterthetotalamountpaidintotheescrowaccountforthisliabilityyear.5$ 6Amountover/under-paid(DifferencebetweenLine4andLine5.)Provideexplanationifnotzero.6$ Note:Attachacopyofyourreceiptorotherproofofdepositfromyourfinancialinstitution. American LegalNet, Inc. www.FormsWorkFlow.com StateofIllinoisCertificationofNon-ParticipatingManufacturerPleaseReviewInstructionsPriortoCompletion.NPM-1p.3of4 Part7:CertificationofDeposits,WithdrawalsandTransfersAttachseparatepageforeachsub-account. TheNPMcertifiesthefollowingtobeacompleterecordofeachdepositandwithdrawalortransferwhichhasoccurredfromanyandallaccountscontainingfundsheldforthebenefitoftheStateofIllinois.Reportendingbalancesofallsuchaccounts,evenwherenodepositsorwithdrawalsoccurred.Attachcopiesofrecordsofthefinancialinstitutiondocumentinganyaccountactivity. IllinoisSub-AccountNumberNameofFinancialInstitution(EscrowAgent) DateDepositAmountWithdrawalorTransferAmountExplanationforWithdrawalorTransfer ColumnTotalsDeposits$Withdrawals/Transfers$EndingBalanceforthisIllinoisSub-Account$ Part8:EscrowInvestmentInformationAttachseparateresponse. 1.InordertobecompliantwithSection5oftheEscrowAgreemententeredintobetweentheNPMandtheEscrowAgent,boththeaggregatefederaltaxcostandtheaggregatefacevalueofthecashandinvestmentsheldintheaccountmustequalorexceedtheaccumulatedrequireddeposits.PleaseconfirmthatallcashandinvestmentsinthequalifiedescrowfundheldforthebenefitoftheStateofIllinoisarecompliantwithSection5oftheEscrowAgreement.Pleasealsoprovideadetailedaccountingregardingeachinvestment,includingwhethertheinvestmentwaspurchasedatapremiumorinsomeothermannerwhichcouldresultinlessthanthefullprincipalamountbeingavailableduringthe25yearsthattheescrowfundsareheldforthebenefitofIllinois.2.ProvidecopiesofallwritteninstructionsprovidedbytheNPMtotheEscrowAgent.Ifinvestmentinstructionsareoral,provideadetailedsummaryoftheinstructions.IfnoinstructionshavebeengiventotheEscrowAgent,pleaseconfirmthattheEscrowAgentisusingthedefaultinstructionsprovidedforinSection4oftheEscrowAgreement.3.HastheNPMgrantedanyrighttothemasterescrowaccountoranystatesubaccounttoathirdparty?Ifyes,pleasestatewhetherthatrightistoownership,reversion,anyaccruedinterest,anysecurityinterest,oranyotherrightorinterest.Provideanydocumentationand/orcorrespondence,includinganyUCCfilingsandSecurityAgreement,ifapplicable,thatestablishthisrightorinterest. American LegalNet, Inc. www.FormsWorkFlow.com StateofIllinoisCertificationofNon-ParticipatingManufacturerPleaseReviewInstructionsPriortoCompletion.NPM-1p.4of4 Part9:DesignatedContact NameTitle MailingAddress CityStateZipCodeCountry PhoneFaxE-Mail Part10:ManufacturerCertification Underpenaltiesofperjury,Istatethat,tothebestofmyknowledge,alloftheinformationcontainedinthisCertificationandanyattacheddocumentsaretrueandaccurateandthatIamapersonauthorizedtobindthemanufacturermakingthiscertificationeitherunderthelawsoftheStateofIllinoisorofthejurisdictionwherethemanufacturerresidesorisorganized.IunderstandthattheAttorneyGeneralmayrequireadditionalinformationand/ordocumentationtodeterminewhetherthemanufacturerqualifiesforlistingontheIllinois Directory. Thisdocumentmustbesignedanddatedbyanauthorizednotarypublic. NPMAuthorizedDesignee(PrintName)Title SignatureofNPMAuthorizedDesigneeDate Subscribedandsworntobeforemethisdate: SignatureofNotaryPublic CountyCommissionExpires Checklistofrequireddocuments NPM-1CertificationofNon-ParticipatingManufacturerNPM-2CertificationofAppointmentofAgentforServiceofProcessNPM-3CertificationofAdditionalInformationNPM-FCertificationofAdditionalInformationforForeignNPMsNPM-PACTCertificationofPACTActInformationNPM-SNon-ParticipatingManufacturer222sSalesInformationNPM-LCCertificationofLittleCigar/CigaretteQualifiedEscrowAgreementSamplepackaging(ifrequired)foreachbrandf