STATE OF ARKANSAS - NON-PARTICIPATING MANUFACTURER QUARTERLY CERTIFICATION FORM CERTIFICATION YEAR 201 *Due Within 20 Days of Conclusion of Each Calendar Quarter CERTIFICATION TYPE: OriginalAmended REPORTING PERIOD: First Quarter Second Quarter Third Quarter Fourth Quarter BUSINESS INFORMATION: Business Name: Contact Person: Address:City: State/Country:ZipCode: Telephone:Email: BRAND SALES: Brand Family: Units Sold During Calendar Quarter: Total Number of Units Sold: To determine the number of units sold for roll-your-own tobacco products, divide the total number of ounces of each brand family by .09. For example, 18 ounces of roll-your-own is 200 units sold (18 367 .09 = 200). QUALIFIED ESCROW ACCOUNT: Financial Institution: Representative222s Name: Address:City: State:ZipCode: Email: Escrow Account Number: Arkansas Sub-Account Number: Date of Escrow Agreement: ESCROW OBLIGATION FOR SALES PERIOD: Total number of units sold in Arkansas during calendar quarter: Statutory rate per cigarette ($0.0188482), as adjusted for inflation: $0. Multiply units sold by the adjusted statutory rate per cigarette: Amount Deposited for Calendar Quarter: An account statement or letter from the escrow agent must be included with this Certification Form. This account statement or letter must indicate: (1) the amount deposited, as indicated above and (2) the date of deposit. The total amount to be deposited into the Qualified Escrow may need to be recalculated at the time of the Annual Certification. American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL INFORMATION: Is the registered agent identified on the company222s most recent Annual Certification still the registered agent for the NPM? YesNo Is the escrow agreement provided with the company222s most recent Annual Certification still accurate, in force, and unchanged? YesNo If you answer to either of the preceding questions was 223no,224 please . SIGNATURE: Authorized Designee: Title: Designee Signature: Date: NOTARY: Subscribed and Sworn Before Me on this Date: Signature of Notary Public: City or County of: My Commission Expires: MAIL THE COMPLETED CERTIFICATION FORM TO: Office of the Arkansas Attorney General ATTN: Tobacco Division 323 Center Street, Suite 200 Little Rock, Arkansas 72201 Certification Forms, including attachments, must be received within 20 days of the conclusion of each calendar quarter. Certification Forms will processed unless all fields are completed and all required attachments have been received. American LegalNet, Inc. www.FormsWorkFlow.com