Montana Department of Justice 2019 Certificate of Escrow Deposit Page 1 of 1 Revised February 2019 by Non-Participating Manufacturer Montana Certificate of Escrow Deposit by Non-Participating Manufacturer Part 1: Manufacturer Identification Name: Street address: City, State, Country, ZIP: Telephone number: E-mail address: Fax number: Name of distributor(s)/wholesaler(s) that sells your cigarettes in Montana and brand(s) sold: Part 2: Liability Year. The liability year for this certificate is: 2019 Part 3: Units Sold 1. Number of individual cigarettes and units of 223roll-your-own224 tobacco sold by the manufacturer during 2019. 1. Part 4: Deposit Amount 2. The base deposit amount for 2007 is $.0188482 per unit sold. The 2019 inflation adjustment is $.0169483 per unit sold. The total amount due, adjusted for inflation is $.0357965. 2. $.0357965 3. Multiply line 1 by line 2 to calculate the total deposit due. 3. Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the institution. Part 5: Financial Institution Name: Street address: City, State, Country, ZIP: Escrow account number: Total amount held in this account: $ Part 6: Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. SWORN AND SUBSCRIBED TO before me this day of , 20 . Date (SEAL) Signature of Authorized Agent Signature of Notary Public Printed Name of Authorized Agent Printed Name of Notary Title City / State: My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com