Page 1 of 9 STATE OF SOUTH CAROLINA TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE [Pursuant to S.C. Code Ann. 24724711-47-10 to -30, and 24724711-48-10 to -110] 2019 NON-PARTICIPATING MANUFACTURER CERTIFICATION FORM NOTICES FILING DEADLINE is April 30, 2019. Certification Forms must be postmarked no later than April 30, 2019 to avoid removal from the South Carolina Tobacco Directory. Please Type or Print. The Attorney General222s Office will not process incomplete or illegible Certification Forms. This Certification Form must be supplemented to reflect any change in information at any time during the year. Any change of information must be submitted 30 days prior to change. The failure to notify the Attorney General222s Office of any changes to this information 30 days prior to any change, including changes in address, may result in removal from the South Carolina Tobacco Directory. The denial of a certificat ion, removal of the Applicant or its brands from any other state222s tobacco directory, or failure to notify the South Carolina Attorney General222s Office of same, may, in the Attorney General222s sole discretion, result in denial of this certification or immediate removal from the South Carolina Tobacco Directory at any time. Please refer any questions to the Office of the Attorney General Tobacco Unit at (803) 734-9927. Mail this completed Certificate of Compliance and attachments to: SC Office of the Attorney General Tobacco Unit P.O. Box 11549 Columbia, SC 29211 PART 1: TOBACCO PRO DUCT MANUFACTURER ID ENTIFICATION A. Type of Certification (check one): Initial Certification 226 Applicant is not currently listed on the South Carolina Tobacco Directory Annual Certification 226 Due April 30, 2019 Supplemental Certification 226 Change of information provided to the Attorney General or request to add additional brands to the South Carolina Tobacco Directory B. Company Information : Applicant Company Name: Mailing Address: City: State: Zip: Country : Phone: Fax: Email: Name of Person Completing Certification: Name of Contact Person ( if different from a bove ) : American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 9 C. Manufacturing Facility Information: Name of Manufacturing Facility (if different from above) : Physical Address: City: State: Zip: Country: Phone: Fax: Email: Name of Factory Manager(s): D. Licenses and Permits: If located in U.S. 226 Manufacturer222s Federal Taxpayer ID Number: TTB Permit Number: Expires: Please indicate if TTB Permit was obtained as a manufacturer or importer: Name of Any other Foreign Manufacturer Permit or License : Expires: Copy of Above Applicable Permit Attached YES NO E. Attorney Information: Attorney Name , if applicable : Firm Name: Firm Mailing Address: City: State: Zip: Country: Phone: Fax: Email: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9 F. Tobacco Product Manufacturer Additional Information: 1. Applicant is the manufacturer (i.e. fabricator) of the brands listed in this certification, which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. YES NO 2. If the answer is 223YES224 to above, please attach photographs of your manufacturing facility including interior and exterior views and indicate on the photographs where the equipment and facilities for manufacturing (i.e. fabricating) the cigarettes, if any, are located. Also, please provide proof of ownership, possession and control of the manufacturing facilities and equipment identified herein. 3. Applicant is the first purchaser anywhere for resale in the United States of cigar ettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. YES NO 4. If the answer is 223YES224 to above, please attach documentation identifying each cigarette manufacturer (i.e. fabricator), its plant address, mailing address, contact person, phone, and fax numbers, and the relationship to Applicant. Identify the location of the transfer of ownership of cigarettes and a copy of every agreement or contract between Applicant and fabricator. Attach additional sheets as necessary to provide a complete response. 5. Applicant is successor of an entity described in questions 1 or 3 above (i.e. manufacturer or first importer). Please identify the predecessor(s). YES NO 6. If Applicant answered 223NO224 to questions 1, 3, and 5 above, please explain the basis for the Applicant222s claim that it is a Tobacco Product Manufacturer as defined under South Carolina Code Ann. 24711-47-10 to -110. Please submit all documentation to support Applicant222s contention. Attach additional sheets as necessary to provide a complete response. G. Organizational Documents: Check One: Response Does Not Provided Apply Attach the following documents or information: 1. Partnership or Association: Current copy of the Certificate of Partnership or the certificate required to be filed by any state, county, or municipality. 2. Corporation: (1) Current copy of the Certificate of Incorporation or other charter; and (2) Extracts of documents listing the officers authorized to sign for the company. 3. Limited Liability Company or other entity: Current copy of the busi ness document(s) filed with a state, county, or municipality when such filing is required. Include a copy of any document indicating persons authorized to sign for the entity. 4. Company Officers/Owners: Provide a list of all company officers and company owners (all persons with an equity interest of 10% or more in the company). Include name, address, phone number, and email address. 5. Affiliates: Provide a list of all company affiliates p ursuant to S.C. Code Ann. 24711 - 47 - 20(b) that also manufactures, imports, distributes, or sells cigarettes or RYO. Include the name, address, and contact information for each affiliate. 6. Agreements with Participating Manufacturers: Identify e very agreement between Applicant and any Participating Manufacturer (PM) or PM Affiliate that relates to the making, importing, distribution, transportation, or sale of each brand family. 7. Agreements Regarding Compliance with the Qualified Escrow Statute: Attach any agreement that Applicant has with another entity regarding the production of cigarettes or funding of Qualified Escrow Fund. American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 9 PART 2: REQUIRED DO CUMENTATION A. General Documentation: Check One: Response Does Not Provided Apply Please attach documentation, which provides the following information: 1. Brand Names: List all brands Applicant seeks to certify for the current sales year. 2. Cigarette or RYO: Indicate whether the brand family is a rolled cigarette or roll - your - own (RYO) tobacco. 3. Identification of Wholesalers and Distributors to Whom Cigarettes were Sold for Distribution in the State of South Carolina: List wholesaler/distributor, address, telephone number, and email address. 4. Units Sold 226 Prior Year: Please execute the attached Affidavit of Units Sold indicating the number of units sold in 2018. Please note that 0.09 oz of RYO constitutes one unit. 5. Units Sold 226 Current Year: Indicate the number of units sold during the current calendar year from January 1, 2019 to date of application. units sold to date in 2019. 6. Prior Manufacturer(s) : Indicate the name and address of all prior tobacco product manufacturers. 7. Current Trademark Holder: Include the name and address of the current trademark holder. Please include a certified copy of the current trademark. 8. Prior Trademark Holder: Include the name and address of all prior trademark holders. 9. Prior Brand Families: List all brands made by Applicant since 1999. Please indicate whether any of the brands listed have been manufactured by a different manufacturer at any time. If yes, please list the brand family, manufacturer, address, and years manufactured. 10. Sample Packaging: Please provide sample of relevant tobacco product packaging. Packaging must be submitted in an electronic format. 11. UPC Codes: Please provide a current listing of all UPC codes of cigarettes and RYO products that are manufactured by your co