STATE OF ARKANSAS CERTIFICATION YEAR Ɣ 2012 - TOBACCO PRODUCTS MANUFACTURER CERTIFICATION FORM TYPE OF CERTIFICATION: Initial Certification Annual Certification *Due On or Before April 30, 2012 Supplemental Certification PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION BUSINESS INFORMATION: Business Name: Address: State: Telephone: Contact Person: City: Zip Code: Email: Yes IS THE COMPANY REPRESENTED BY COUNSEL? IDENTIFICATION OF COUNSEL: Firm Name: Address: State: Telephone: No Counsel’s Name: City: Zip Code: Email: PART 2: DESIGNATION OF TOBACCO PRODUCT MANUFACTURER AS OF THE DATE OF CERTIFICATION, THE COMPANY IS A: Participating Manufacturer under the tobacco Master Settlement Agreement that is generally performing its financial obligations, as required by ARK. CODE ANN. § 26-57-261. Non-Participating Tobacco Product Manufacturer in full compliance with ARK. CODE ANN. § 26-57-261, including all quarterly payments that may be required by ARK. CODE ANN. § 26-57-1305(e). PART 3: BRAND FAMILY IDENTIFICATION ĺ PMs must complete column 1. NPMs must complete columns 1 and 2. 1. Brand Family: 2. Units Sold During Sales Period Total Number of Units Sold: American LegalNet, Inc. www.FormsWorkFlow.com ĺBy including a brand family in this Certification Form, a Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of calculating its payments under the Master Settlement Agreement. By including a brand family in this Certification Form, a Non-Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of escrow. Despite this, the Office of the Arkansas Attorney General retains the discretion to determine that the listed brand family is the product of another tobacco product manufacturer. PACKAGING OR LABELING: For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the packaging or labeling. Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged FIRE-SAFE COMPLIANCE: Are each of the cigarette brand families listed herein fire-safe compliant and certified with Arkansas Tobacco Control, as required pursuant to ARK. CODE ANN. § 20-27-201, et seq.? Yes No If your answer to the preceding question, was “no,” please explain the basis for the request to list the brand on the Approved-for-Sale Tobacco Products Directory published pursuant to ARK. CODE ANN. § 26-57-1303(b). Explanation: DEPARTMENT OF HEALTH AND HUMAN SERVICES INGREDIENT LIST: For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the Certificate of Compliance issued by the Department of Health and Human Services, Centers for Disease Control and Prevention, and the Office on Smoking Health with respect to the ingredient list submission pursuant to 15 U.S.C. § 1335a. FEDERAL TRADE COMMISSION ROTATION PLAN: For each Brand Family identified in Part 3 of this Certification Form, provide a copy of the complete warning rotation plan submitted to the Federal Trade Commission (“FTC”) pursuant to 15 U.S.C. § 1333 and a copy of the approval letter from the FTC for each brand family. TOTAL NATIONWIDE SALES ON WHICH FEDERAL EXCISE TAX WAS PAID: ĺ In the case of a domestic tobacco product manufacturer, copies of Tobacco Tax Bureau Form 5000.24 supporting the total sales number must be included with this Certification Form. In the case of a foreign tobacco product manufacturer, a copy of Tobacco Tax Bureau Form 5220.6 supporting the total sales number must be included. TOTAL NATIONWIDE SALES REPORTED PURSUANT TO 15 U.S.C. § 376: ĺ Copies of all reports made pursuant to 15 U.S.C. § 376 must be included with this Certification Form. The company submitting this form must submit reports to states other than Arkansas. American LegalNet, Inc. www.FormsWorkFlow.com PART 4: BUSINESS AND OWNERSHIP INFORMATION A. Participating and Non-Participating Tobacco Product Manufacturers FABRICATION OF BRAND FAMILIES: Does the company submitting this certification itself fabricate the brand families identified in Part 3 of this Certification Form? Yes No If your answer to the preceding question was “no,” please explain the basis for the company’s submission of this Certification Form. Explanation: MANUFACTURING FACILITY IDENTIFICATION: Facility: Address: Manager: Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged MANUFACTURER EQUIPMENT IDENTIFICATION: Type/Name of Equipment: Manufacturer of Equipment: Serial Number: Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged ACCESS TO MANUFACTURING FACILITY AND EQUIPMENT: Do other companies have access to or utilize any of the manufacturing facilities identified herein? Yes No If your answer to the preceding question was “yes,” please explain. Explanation: American LegalNet, Inc. www.FormsWorkFlow.com PHOTOGRAPH OR DIAGRAM OF INTERIOR OF MANUFACTURING FACILITIES: Provide a photograph or diagram of the interior of each of the manufacturing facilities identified herein, specifically indicating on the photograph or diagram where the manufacturing equipment used in the fabrication of cigarettes is located. Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged PHOTOGRAPH OF EXTERIOR OF MANUFACTURING FACILITIES: Provide a photograph of the exterior of each of the manufacturing facilities identified herein. Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged PROOF OF OWNERSHIP OF MANUFACTURING FACILITIES: Provide proof of ownership, possession, and control of each of the manufacturing facilities identified herein. Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged PROOF OF OWNERSHIP OF MANUFACTURING EQUIPMENT: Provide proof of ownership, possession, and control of the manufacturing equipment used by the company in the fabrication of cigarettes at each of the manufacturing facilities identified herein. Information Previously Provided to Office of the Arkansas Attorney General and Remains Unchanged U.S. DEPARTMENT OF TREASURY, TOBACCO TAX BUREAU PERMIT NUMBER: ĺ A copy of the permit issued by the U.S. Department of Treasury, Tobacco Tax Bureau must be included with this certification form. IDENTIFICATION OF WHOLESALERS, DISTRIBUTORS, OR STAMPING AGENTS TO WHOM CIGARETTES WERE SOLD FOR DISTRIBUTION IN THE STATE OF ARKANSAS: Wholesaler: Address: Telephone: CRIMINAL ACTIVITY: Has the company submitting this form or any of its affiliates, sales entity affiliates, officers, or directors pled guilty or nolo contendere to or been found guilty of a felony crime relating to the sale or taxation of cigarettes or tobacco products? Yes No If your answer to the preceding question was “yes,” please explain. Explanation: American LegalNet, Inc. www.FormsWorkFlow.com ADVERTISING PRACTICES: Does the company advertise or sell cigarettes via the Internet or in catalogs or other print media for purposes of selling such cigarettes to individual consumers, including consumers in the State of Arkansas? Yes No Yes No Yes No If your answer to the preceding questions was “yes,” please explain. Explanation: JENKINS ACT COMPLIANCE: For each of the past 12 calendar months, has the company provided the reports required by the Jenkins Act, 15 U.S.C. § 375, et seq., as amended, to the Arkansas Department of Finance and Administration and Office of the Arkansas Attorney General? If your answer to the preceding question was “no,” please explain. Explanation: DIRECTORY STATUS: Have either the company submitting this form or its brand families been removed the approved-for-sale tobacco products directory of any state since the submission of the Tobacco Products Manufacturer Certification Form for the last year? If your answer to the preceding question was “no,” please explain. Explanation: B. Non-Participating Manufacturers Only IDENTIFICATION OF DIRECTORS, MEMBERS, OFFICERS, AND OWNERS OF THE COMPANY: Interested Party: Address: Telephone: American LegalNet, Inc. www.FormsWorkFlow.com ASSOCIATION WITH OTHER TOBACCO PRODUCT MANUFACTURERS: Are any of the individuals or entities identified in the preceding question also directors, members, officers, owners of other PMs or NPMs? Yes No Yes No If your answer to the preceding question was “yes,” please explain. Explanation: RECLASSIFICATION OF PRODUCTS AS CIGARETTES OR ROLL-YOUR-OWN: Have any tobacco products manufactured or sold by the company been reclassified within the last two years as cigarettes or RYO product by a federal, state, or local government entity? If your answer to the preceding question was “yes,” please explain. Explanation: PART 5: NON-PARTICIPATING MANUFACTURER CERTIFICATION NON-PARTICIPATING MANUFACTURER’S REGISTERED AGENT FOR SERVICE OF PROCESS: Company: Address: City: State: Zip Code: Telephone: Fax: Email: ĺ A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form. Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas. CONSENT TO BE SUED: Provide an executed copy of the Consent to be Sued form prepared by the Office of the Arkansas Attorney General. ĺ A properly executed copy of the Consent to be Sued form must be included with this Certification Form. ACCEPTANCE OF JOINT-AND-SEVERAL LIABILITY BY IMPORTERS: In the case of Non-Participating Manufacturers located outside of the United States, provide an executed copy of the Acceptance of Joint-and-Several Liability by Importers form prepared by the Office of the Arkansas Attorney General. ĺ A properly executed copy of the Acceptance of Joint-and-Several Liability by Importers form must be included with this Certification Form. American LegalNet, Inc. www.FormsWorkFlow.com IMPORTER’S REGISTERED AGENT FOR SERVICE OF PROCESS: Company: Address: City: State: Zip Code: Telephone: Fax: Email: ĺ A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form. Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas. BONDING: Does the company submitting this form have a bond in place to cover escrow liability for sales made in Arkansas during the sales year? Yes No ĺ If your answer to the preceding question was “yes,” a copy of such bond must be included with this Certification Form. QUALIFIED ESCROW ACCOUNT: Financial Institution: Address: State: Email: Arkansas Sub-Account Number: Representative’s Name: City: Zip Code: Escrow Account Number: Date of Escrow Agreement: ĺ A copy of the current governing Escrow Agreement and any Amendments thereto must be included with this Certification Form. ESCROW OBLIGATION FOR SALES PERIOD: Total Number of Units Sold in Arkansas during Sales Period: Statutory rate per cigarette ($0.0188482), as adjusted for inflation: $0.0274350 Multiply Units Sold by the adjusted statutory rate per cigarette: Amount Deposited for Sales Year: ĺ 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. ĺ The inflation adjustment used herein may not be accurate for Quarterly Certifications; the total amount to be deposited into the Qualified Escrow may need to be recalculated at the time of the Annual Certification. TOTAL AMOUNT HELD IN ESCROW FOR ARKANSAS: Total amount held in the Qualified Escrow account for all years: $ DEPOSITS AND WITHDRAWALS DURING SALES PERIOD: Date: Deposit Amount: Withdrawal Amount: Totals: $ $ Balance: $ American LegalNet, Inc. www.FormsWorkFlow.com ĺ An account statement from the escrow agent must be included with this Certification Form, indicating the complete account history for the account/sub-account for the State of Arkansas for all sale years, including all deposits, withdrawals, interest earned, and a current account balance. PART 6: SIGNATURE Under penalty of perjury, I state that the information contained in this Certification Form is true and correct. Authorized Designee: Designee Signature: Title: Date: ĺ The knowing submission of false or inaccurate information to the Office of the Arkansas Attorney General could result in a civil penalty being issued against you in an amount up to $10,000.00. PART 7: NOTARY Subscribed and Sworn Before Me on this Date: Signature of Notary Public: City or County of: My Commission Expires: ĺ Seal of Notary must be included and should overlap the right-hand column of the above box. PART 8: CHECKLIST AND MAILING PRIOR TO MAILING, PLEASE ASSURE THAT THE FOLLOWING HAS BEEN PROVIDED: Brand Family Packaging or Labeling Exterior Photograph of Facility Ingredient List Proof of Ownership of Facility Rotation Plan Proof of Ownership of Equipment Tobacco Tax Bureau Form 5000.24 or 5220.6 U.S. Department of Treasury Permit Nationwide Reports Under 15 U.S.C. § 376 Signature Interior Photography or Diagram of Facility Notary IN THE CASE OF A NON-PARTICIPATING MANUFACTURER, PLEASE ALSO ASSURE THAT THE FOLLOWING HAS BEEN PROVIDED: Manufacturer’s Statement from Registered Agent NPM or Importer Bond Documentation Consent to be Sued Escrow Agreement and Amendments Acceptance of Joint-and-Several Liability Account Statement with Complete History Importer’s Statement from Registered Agent MAIL THE COMPLETED CERTIFICATION FORM TO: Office of the Arkansas Attorney General ĺCertification Forms, including attachments, must be received on or before ATTN: Tobacco Division April 30, 2012. ĺCertification Forms will be returned and left unprocessed unless all fields are 323 Center Street, Suite 200 completed and all required attachments have been received. Little Rock, Arkansas 72201 American LegalNet, Inc. www.FormsWorkFlow.com