STATE OF WYOMING NON-PARTICIPATING MANUFACTURER CERTIFICATION FORM Pursuant to W yo. Stat. §§ 9-4-1201 and 1202; 9-4-1205 through 9-4-1210 W ho is required to fill out the certification form? • • Every non-participating tobacco product manufacturer whose cigarettes or roll-your-own are sold in the State of W yoming, whether directly or through any distributor, retailer, or similar intermediary shall execute and deliver a Certification Form to the Attorney General on April 30 annually for prior year sales, and to certify brands for the current year. The Certification Form is required by a new non-participating manufacturer to certify to sell cigarettes or roll-your-own in the State of W yoming, whose prior year sales are zero. Only certified non-participating manufacturers are eligible to have their brands and brand styles listed in W yoming’s Directory of Certified Tobacco Product Manufacturers Their Brands and Brand Families. If a particular brand is not listed in The Directory, it is not legal to be sold, offered for sale, or possessed for sale in the State of W yoming. Please Type or Print all Information Part 1: M anufacturer’s Identification - ( Also See and Complete Attachment A.) Name: ___________________________________________________________Phone:______________________________ Address: _____________________________________________ ____________Fax:_______________________________ _________________________________________________________________Email:______________________________ _________________________________________________________________W ebsite:____________________________ How Long in Business?_________________________________________________________________________________ Part 2: Identify the Prior Sales Year: _____________ (Complete a separate Certification Form for each sales year.) Part 3: Units Sold Total number of individual cigarettes and Aroll-your-own@ tobacco units sold by the Manufacturer during the sales year. Cigarettes: _____________________Roll-Your- Own (number of ounces sold divided by .09):____________________________ Total Units Sold:__________________ Part 4: Escrow Calculation on Total Units Sold: Multiply units sold in Part 3 by the appropriate rate in Part 4. Year: Rate: 2003-2006 0.0167539 2007 on 0.0188482 The appropriate deposit subtotal is: $______________________(a) American LegalNet, Inc. www.FormsWorkflow.com Non-participating Manufacturer Certification Form - Page 2 Multiply the deposit subtotal above (a) by the appropriate inflation adjustment to equal (b). Year: Rate: 2003 .1636275 2004 .2015103 2005 .2425497 The appropriate inflation adjustment is: $______________________(b) The total of (a) and (b) is the amount required to be paid in to the Qualified Escrow Fund for the State of W yoming by the Manufacturer for the identified sales year. $_______________________ W yoming requires quarterly escrow deposits, which are due by the last day of the next month following the end of each quarter. Attach proof of escrow balance for the above. Part 5: Financial Institution for Qualified Escrow Name of Institution:____________________________________________________________________________________ Address:______________________________________________________________City:___________________________ State:______________Zip:_______________Phone:______________________________Fax:________________________ Acct.#________________________________________Sub Acct.#______________________________________________ Part 6: Brand/s Listing - (See and Complete Attachment B.) Part 7: Qualified Escrow Agreement Attach a copy of the Qualified Escrow Agreement, executed by the M anufacturer, to govern the payments into a Qualified Escrow Fund, made by the M anufacturer in accordance with W yo. Stat. § 9-4-1202, on behalf of the State of Wyoming, if you are certifying for the first time, or did not certify the previous year. Part 8: Registered Agent If the Manufacturer has not registered with the W yoming Secretary of State to do business in the State of W yoming as a foreign corporation or business entity, the Manufacturer must appoint and continually engage, without interruption, the services of an agent in this state to act as agent for service of process on whom all process may be served in any manner authorized by law. If the Manufacturer has registered with the W yoming Secretary of State to do business in W yoming as a foreign corporation or business entity, please indicate as such. If the Manufacturer has not registered with the W yoming Secretary of State to do business in W yoming as a foreign corporation or business entity, please submit the following: Name of Registered Agent______________________________________________________________________________ W yoming Address:____________________________________________________________________________________ Phone:___________________________________Contact:____________________________________________________ G Check if registered with the W yoming Secretary of State. Attach a paid invoice as proof that the services of a registered agent have been contracted, and which indicates the period covered by the invoice. American LegalNet, Inc. www.FormsWorkflow.com Non-Participating Manufacturer Certification Form - Page 3 Be advised that the Manufacturer must provide notice to the Office of the Attorney General thirty (30) calendar days prior to he termination of the authority of the appointed agent described in Part 8, Subsections 1-4 above. In the event of such termination, the Manufacturer must provide proof of the appointment of a new Agent, together with the information contained in Part 8, Subsections 1-4 above, no less than five (5) calendar days prior to the termination of the existing Agent=s appointment. In the event that the Agent described in Part 8, Subsections 1-4 above, terminates the agency appointment, the Manufacturer must notify the Attorney General of the termination within five (5) calendar days, and shall include proof of the appointment of a new Agent, together with the information contained in Part 8, Subsections 1-4 above, to the Office of the Attorney General. Part 9: Signature I certify, under penalty of false swearing, that all of the information provided in this three-page Certification Form, as well as attachments required, and Attachments A and B is true, accurate, and complete. I further certify that the above named Manufacturer is in full compliance with W yo. Stat §§ 9-4-1201 and 1202 and W yo. Stat '' 9-4-1205 through 1210. ____________________________________________________________________________________________________ _ Name of Authorized Manufacturer Representative and Title (please print or type): ____________________________________________________________________________________________________ Signature of Authorized Manufacturer Representative: Date: ----------------------------------------------------------------------------------------------------------------------------------------------------------M ail this Office of the Attorney General Certification Tobacco Settlement Unit Form to: State Capitol, Room 123 Cheyenne, W Y 82002 And Include: Attachments A and B Copy of Qualified Escrow Agreement, if required by #7 Proof of Contract for Registered Agent Services Proof of Escrow Balance for 2005 sales Copy of wholesale license issued by the Wyoming Department of Revenue American LegalNet, Inc. www.FormsWorkflow.com