Maryland Quarterly Certificate of Compliance of Escrow Funding for 2019 SalesCalendar Year 2019Please note: This form must be filed by nonparticipating manufacturersrequired to make quarterly escrow payments and certifications pursuant toCOMAR 02.07.01. For instructions and definitions of terms used herein, please refer to MarylandAnnotated Code, Business Regulation Article 24724716-401 et seq. & 24724716-501 et seq.(available at www.marylandattorneygeneral.gov/Pages/Tobacco/Statedirectory.aspx).1.Nonparticipating Manufacturer222s identificationName:Address: Phone: Fax: 2.Quarter being reportedG Jan. 1, 2019 226 March 31, 2019GApril 1, 2019 226 June 30, 2019GJuly 1, 2019 226 Sept. 30, 2019G Oct. 1, 2019 226 Dec. 31, 20193.Units sold for quarterIndicate the number of individual cigarettes and "roll-your-own" tobacco sold in Marylandin this quarter, whether sold directly or through a distributor, retailer or other intermediary,for the 2019 quarter indicated above: 1 American LegalNet, Inc. www.FormsWorkFlow.com 4.Escrow rate and paymentThe escrow rate, adjusted for the minimum inflation rate, is $0.0357965.Number of units sold (from #3) to be multiplied by inflation-adjustedescrow rate of $0.0357965.Total amount to be deposited in escrow:$5.Financial InstitutionName of Institution:Address of Institution:Phone Number:Account Number:Date Account Opened:Total Amount Held for State of Maryland: $6.DocumentationIf this is your initial deposit, attach a copy of your executed escrow agreement, and copiesof amendments, if any, to your escrow agreement.For all deposits, attach copies of your receipt or other proof of deposit from yourfinancial institution.7.Certification I certify that the above information is true and correct.Signature of Authorized Agent:Name of Authorized Agent:Title of Authorized Agent: Date: 8.Mail this certificate of compliance to:Aravind Muthukrishnan, Tobacco Enforcement UnitOffice of the Attorney General of Maryland200 St. Paul Place, 20 FloorthBaltimore, Maryland 212022 American LegalNet, Inc. www.FormsWorkFlow.com