STATE OF CALIFORNIA DEPARTMENT OF JUSTICE ACKNOWLEDGMENT OF RECEIPT & REVIEW OF NPM RESERVE FUND STATUTE, IMPLEMENTING REGULATIONS & FORMS JUS-TOB 5 Rev. 02/04 PAGE 1 of 2 QUARTER ENDING: NOTE TO DISTRIBUTORS:YOU MAY STAMP AND SELL ONLY THE BRANDS OF MANUFACTURERSWHICH ARE LISTED ON THE ATTORNEY GENERAL'S DIRECTORY: HTTP://CAAG.STATE.CA.US/. PRODUCTS NOT LISTED ON THE DIRECTORY ARE CONTRABAND AND SUBJECT TO SEIZURE AND FORFEITURE This Acknowledgment of Receipt & Review Form Is Not Valid Unless a stamp from the Attorney General's Office appears in the box below. FOR OFFICIAL USE ONLY A Copy of This Stamped Acknowledgment of Receipt & Review Form Must Be Provided to California Distributors And Wholesalers Which Sell Your Product. PART 1: TOBACCO PRODUCT MANUFACTURER'S IDENTIFICATION * COMPANY NAME: STREET ADDRESS: CITY: EMAIL: STATE: PHONE NUMBER: FAX NUMBER: ZIP CODE: BOARD OF EQUALIZATION (BOE) MANUFACTURER'S LICENSE NO.: *All manufacturers (i.e., fabricators) must complete and sign this form. Use as many copies of this form as needed. PART 2: BRANDS TO BE SOLD AND SALES YEAR THE FIRST YEAR OF SALES OF CIGARETTES TO CALIFORNIA CONSUMERS BY THE ABOVE COMPANY IS: THE BRAND NAMES TO BE SOLD IN CALIFORNIA: (ATTACH A SEPARATE SHEET IF NECESSARY) PART 3: AUTHORIZED COMPANY OFFICERS, OWNERS & AGENTS FOR SERVICE OF PROCESS NAME: NAME: NAME: NAME: TITLE: TITLE: TITLE: TITLE: PLEASE ATTACH ADDITIONAL SHEET(S), AS NECESSARY, TO PROVIDE A COMPLETE RESPONSE. PART 4: ACKNOWLEDGMENT OF RECEIPT OF COPY OF RESERVE FUND STATUTE, IMPLMENTING REGULATIONS AND FORMS I ACKNOWLEDGE RECEIPT AND REVIEW OF A COPY OF THE NPM RESERVE FUND STATUTE HEALTH & SAFETY CODE, SECTIONS 104555-104557, REVENUE & TAXATION CODE, SECTION 30165.1, THE IMPLEMENTING REGULATIONS (TITLE 11, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS SECTIONS 999.10-999.14) AND FORMS (ESCROW AGREEMENT ((JUS-TOB 6)), CERTIFICATE OF COMPLIANCE (JUS-TOB 3), BRAND FAMILIES UNIT SALES SCHEDULE 1 (JUS-TOB 4). INITIALS: DATE: American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF JUSTICE ACKNOWLEDGMENT OF RECEIPT & REVIEW OF NPM RESERVE FUND STATUTE, IMPLEMENTING REGULATIONS & FORMS JUS-TOB 5 Rev. 8/07 PAGE 2 of 2 PART 5: ACKNOWLEDGMENT OF CALCULATION METHOD I ACKNOWLEDGE THAT THE NPM RESERVE FUND STATUTE REQUIRES OUR COMPANY TO DEPOSIT BY APRIL 15TH NEXT YEAR THE AMOUNTS DETERMINED ACCORDING TO THE FORMULA CALCULATION DESCRIBED BELOW. TO CALCULATE THE BASE AMOUNT (THE RATE FOR THE SALES YEAR) TIMES (THE NUMBER OF CIGARETTES SOLD THAT YEAR) FOR THE APPROPRIATE SALES YEAR, THE FOLLOWING ARE THE RATES PER CIGARETTE THAT OUR COMPANY SELLS IN CALIFORNIA: FOR THE SALES YEAR: (USE THE RATES LISTED BELOW TO CALCULATE THE APPROPRIATE DEPOSIT AMOUNT) 2000 - THE RATE PER CIGARETTE IS ......................................... 0.0104712 2001 - 2002 - THE RATE PER CIGARETTE IS .............................. 0.0136125 2003 - 2006 - THE RATE PER CIGARETTE IS .............................. 0.0167539 2007 AND THEREAFTER - THE RATE PER CIGARETTE IS ................... 0.0188482 THE APPROPRIATE RATE FOR OUR FIRST YEAR OF CIGARETTE SALES IN CALIFORNIA IS:............................................._______________ TO CALCULATE THE TOTAL AMOUNT TO BE DEPOSITED INTO ESCROW, THE INFLATION ADJUSTMENT ACCORDING TO EXHIBIT C* OF MSA IS ADDED TO THE BASE AMOUNT. INITIALS: DATE: PART 6: ACKNOWLEDGMENT THAT COPIES OF INFLATION ADJUSTMENT CALCULATION AND PROOF OF DEPOSIT IS REQUIRED I ACKNOWLEDGE ALSO THAT MY COMPANY IS REQUIRED TO ATTACH A COPY OF OUR INFLATION ADJUSTMENT CALCULATION AND OUR RECEIPT OR OTHER PROOF OF DEPOSIT FROM OUR FINANCIAL INSTITUTION. INITIALS: PART 7: NOTARIZED SIGNATURE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA, I DECLARE THAT I AM AUTHORIZED TO CERTIFY, ON BEHALF OF THE TOBACCO PRODUCT MANUFACTURER NAMED IN PART 1, THAT ALL OF THE CERTIFICATIONS AND INFORMATION CONTAINED IN THIS ACKNOWLEDGMENT FORM IS COMPLETE AND ACCURATE. THIS DOCUMENT MUST ALSO BE SIGNED AND DATED IN FRONT OF AN AUTHORIZED NOTARY PUBLIC, WHO ALSO SIGNS AS A WITNESS. DATE: NAME (TYPE OR PRINT): SIGNATURE OF AUTHORIZED AGENT: SUBSCRIBED AND SWORN TO BEFORE ME ON THIS DATE: SIGNATURE OF NOTARY PUBLIC: COMMISSION EXPIRES: TITLE: DATE: CITY OF: THIS FORM MUST BE FILED WITH THE ATTORNEY GENERAL OFFICE: MAILING ADDRESS: OFFICE OF THE ATTORNEY GENERAL FOR THE STATE OF CALIFORNIA TOBACCO LITIGATION & ENFORCEMENT SECTION P. O. BOX 944255 SACRAMENTO, CA 94244-2550 STREET ADDRESS: OFFICE OF THE ATTORNEY GENERAL FOR THE STATE OF CALIFORNIA TOBACCO LITIGATION & ENFORCEMENT SECTION 1300 I STREET, SUITE 125 SACRAMENTO, CA 95814 OR American LegalNet, Inc. www.FormsWorkFlow.com