OFFICE OF THE KANSAS ATTORNEY GENERAL NON-PARTICIPATING MANUFACTURER CERTIFICATION FORM R EVISED J ANUARY 28, 2011 TYPE OF CERTIFICATION This certification is: Initial Supplemental Renewal MANUFACTURER INFORMATION Manufacturer: ____________________________________________________________ Mailing Address: ____________________________________________________________ ____________________________________________________________ Street Address: ____________________________________________________________ ____________________________________________________________ The street address should be the physical location of the manufacturing plant. Phone Number: ________________________ E-Mail Address: ____________________________________________________________ Website: ____________________________________________________________ Federal Taxpayer ID Number: Fax Number: ___________________ ____________________________________________________________ Only applies if manufacturer is registered in the United States. Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com IMPORTER INFORMATION Complete this section only if you are a manufacturer located outside of the United States. Importer Name: ____________________________________________________________ Contact Name: and Title: ____________________________________________________________ Mailing Address: ____________________________________________________________ ____________________________________________________________ Phone Number: ________________________ Fax Number: ___________________ E-Mail Address: ____________________________________________________________ Federal Taxpayer ID Number: ____________________________________________________________ Important Notice: Pursuant to K.S.A. 50-6a04(c)(3)(I), manufacturer must submit an original United States Importer Declaration Form executed by each entity who imports any of its brand families into the United States to be sold in Kansas. The form is available at www.ksag.org/tobacco. DESIGNATED CONTACT Identify the person that you wish to receive all correspondence and official notifications. Failure to designate an official contact person will result in an incomplete certification. Contact Name: ____________________________________________________________ Organization: ____________________________________________________________ Relationship to Manufacturer: Mailing Address: ____________________________________________________________ E.g., Attorney, Importer, Tax Compliance Manager, etc. ____________________________________________________________ ____________________________________________________________ Phone Number: ________________________ Fax Number: ___________________ E-Mail Address: ____________________________________________________________ Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENT AGENT FOR SERVICE OF PROCESS Resident Agent: ____________________________________________________________ Mailing Address: ____________________________________________________________ ____________________________________________________________ Phone Number: ________________________ Fax Number: ___________________ E-Mail Address: ____________________________________________________________ ESCROW FUND INFORMATION Financial Institution: ____________________________________________________________ Contact Name and Title: ____________________________________________________________ Address: ____________________________________________________________ ____________________________________________________________ Phone Number: ________________________ Fax Number: ___________________ E-Mail Address: ____________________________________________________________ Primary Escrow Account Number: ____________________________________________________________ Kansas SubAccount Number(s): ____________________________________________________________ Execution Date of Most Recent Escrow Agreement: ____________________________________________________________ Amount Deposited Into Escrow For Previous Sales Year (1s –4th Quarter 2010): ____________________________________________________________ Total Units Sold in Previous Sales Year (1st–4th Quarter 2010): ____________________________________________________________ Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com BRAND FAMILIES TO BE CERTIFIED Complete this page for each brand family you wish to certify for sale in Kansas. Only list one brand family per sheet. Attach additional sheet(s) as needed. PLEASE IDENTIFY: PAGE ____ OF _____ BRAND FAMILY INFORMATION Brand Family: _______________________________ Cigarette RYO (Check one only.) CURRENT MANUFACTURER (Check appropriate box below. You MUST choose one.) The certifying manuafcturer actually manufacturers the brand family identified above. A different manufacturer, other than the certifying manufacturer, actually manufacturers the brand family identified above. Attach a copy of all contract manufacturing agreements between the certifying manufacturer and the actual manufacturer for the brand family identified above. OTHER MANUFACTURERS (Check appropriate box below. You MUST choose one.) Provide the name and address of any manufacturer(s), other than the certifying manufacturer, who actually manufacturered the brand family identified above at any time between January 1, 2010, and the current date. Name: ____________________________________________________________ Address: ____________________________________________________________ Not applicable. TRADEMARK INFORMATION (Check appropriate box below. You MUST choose one.) Manufacturer owns a United States Registered Trademark for the brand family identified above. Trademark serial or registration number: ____________________________________ Manufacturer does not own a United States Registered Trademark for the brand family identified above. Attach any written contracts or agreements indicating the authority to manufacture the brands, or written authorization from the trademark holder. Trademark serial or registration number: ____________________________________ A United States Registered Trademark does not exist for the brand family identified above. Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com BRAND FAMILIES TO BE REMOVED List all cigarette and roll-your-own (“RYO”) tobacco brand families currently on the Kansas Directory of Compliant Non-Participating Manufacturers that you request to be removed. ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ACKNOWLEDGEMENT OF ADDITIONAL REQUIREMENTS Manufacturer acknowledges that it is responsible for complying with all federal and state regulations, including the Federal Prevent All Cigarette Trafficking Act (“PACT Act”) and the Federal Family Smoking Prevention and Tobacco Control Act. Manufacturer acknowledges that any cigarettes in this certification that are not also certified under the Fire Safety Standards and Firefighter Protection act (K.S.A. 31-601 et seq.) are not legal for sale in Kansas. he following attachments must be submitted withDOCUMENTATION Failure to attach the SUPPLEMENTAL this certification form. Submit the following attachments with this certification form. If any requested attachments are not applicable, please mark “N/A.” Failure to attach the documents in their entirety will result in an incomplete certification. ATTACHED N/A CDC Approval Letter. Provide a copy of the current United States Center for Disease Control (“CDC”) ingredient listing compliance letter(s) for each cigarette brand family. If a letter for this year’s certification is not yet available, provide a copy of the written request addressed to the CDC. Contract Manufacturing Agreements. Provide a copy of all contract manufacturing agreements for any brand family of cigarettes or RYO tobacco that is manufactured by an entity other than the certifying manufacturer. Escrow Account Documentation. Provide written evidence or verification of each deposit, withdrawal, or transfer made into or from your qualified escrow fund in the preceding calendar year, including the amount and date of each such deposit, withdrawal, or transfer. Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHED N/A Escrow Agreement. Provide an executed copy of the manufacturer’s current Escrow Agreement. Include any amendments or attachments to such agreement. FTC Approval Letter. Provide a copy of the current United States Federal Trade Commission (“FTC”) approval letter(s) for health-warning rotation plan(s) for each of the cigarette brand families. If a letter for this year’s certification is not yet available, provide a copy of the written request addressed to the FTC. Packaging Samples. Provide a packaging sample for each cigarette or RYO tobacco brand family. Digital copies of packaging samples are preferred. If the packaging samples provided with last year’s certification have not changed, you may disregard this requirement and check the box designated “N/A.” Resident Agent Letter. Provide an original letter from the resident agent accepting appointment as agent for service of process in the state of Kansas for sales year 2011. TTB Permit. Provide a copy of the manufacturer’s or first importer’s United States Alcohol and Tobacco Tax and Trade Bureau (“TTB”) permit. United States Importer Declaration Form. Provide an original United States Importer Declaration Form executed by each entity who imports any of manufacturer’s brand families into the United States to be sold in Kansas. I certify that the above required documentation to be submitted with this certification is attached. I understand that failure to provide the required documentation will result in an incomplete certification. ____________________________________ Signature of Authorized Officer or Agent Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION OF CERTIFICATION I certify that, to the best of my knowledge, all of the information contained in this certification and any attachments are true and accurate, and that I am authorized, under the laws of the state of Kansas or the jurisdiction where the manufacturer resides or is organized, to bind the manufacturer making this certification. I certify that manufacturer is in full compliance with K.S.A. 50-6a03(b), and amendments thereto, and any rules or regulations promulgated pursuant to K.S.A. 50-6a01 et seq. I certify that, for any brand family acquired from a previous manufacturer, all previous escrow payments required by K.S.A. 50-6a03 have been paid in full. I certify that manufacturer is either registered to do business in the state of Kansas, or manufacturer has appointed a resident agent for service of process in Kansas. I certify that manufacturer has established and continues to maintain a qualified escrow fund, and that manufacturer has executed an escrow agreement that governs the qualified escrow fund and that such escrow agreement has been reviewed and approved by the Kansas Attorney General. I certify that manufacturer consents to the jurisdiction of the District Court of the Third Judicial District, Shawnee County, Kansas, for the purposes of enforcing K.S.A. 50-6a01 et seq. I certify that by including a brand family in this certification, manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of calculating its escrow payments pursuant to K.S.A. 50-6a03(b), including any brand families for which manufacturer does not own a United States Registered Trademark nor an exclusive right of use. I certify under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. Executed this _______ day of __________________, 20_____. SUBMISSION OF NPM CERTIFICATION FORM Mail this completed form and all attachments to: Office of the Kansas Attorney General Attn: Tobacco Enforcement Unit 120 S.W. 10th Ave., 2nd Floor Topeka, KS 66612-1597 ____________________________________ Signature of Authorized Officer or Agent ____________________________________ Name (Please Print) ____________________________________ Title (Please Print) Non-Participating Manufacturer Certification Form Revised January 28, 2011 Page 7 of 7 American LegalNet, Inc. www.FormsWorkFlow.com