STATE OF CALIFORNIA JUS-TOB4 (Rev. 02/2011) DEPARTMENT OF JUSTICE BRAND FAMILIES UNIT SALES SCHEDULE 1 (Rev. & Tax Code § 30165.1, Health & Saf. Code §§ 104555-104557) PAGE 1 of 2 Original Amended Date: SALES YEAR: 20 THIS FORM MUST BE SUBMITTED WITH THE CERTIFICATE OF COMPLIANCE (JUS-TOB3) FOR THE SPECIFIED REPORTING PERIOD. Company is a (Check One): Company Name: Street Address: Phone Number: Fax Number: E-mail Address: Manufacturer Importer Board of Equalization License Number: *If your Company is required to make deposits into escrow more frequently than annually, indicate the specified reporting period for which deposit was made. Reporting Period: From (month/date/year): to INSTRUCTIONS · · · · Column A: List all Brand Families sold during this reporting period. Column B: Write "C" after any brand style of Cigarettes, (RYO) after any brand of Roll-Your-Own tobacco, and "LC" after any brands of Little Cigars. Column C: List all units sold in California during the reporting period, i.e., annual, quarterly or other specified period. (1 Unit = an individual cigarette or individual Little Cigar or .09 oz. of RYO.) Column D: If the reporting company is not the manufacturer (i.e. fabricator), provide the name and street address of the manufacturer(s). Attach additional sheets, as necessary, to provide a complete answer. A BRAND FAMILY NAME(S) B PRODUCT TYPE C UNITS SOLD D MANUFACTURER (i.e. FABRICATOR) NAME & ADDRESS Complete information and declaration on page 2. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA JUS-TOB4 (Rev. 02/2011) DEPARTMENT OF JUSTICE BRAND FAMILIES UNIT SALES SCHEDULE 1 (Rev. & Tax Code § 30165.1, Health & Saf. Code §§ 104555-104557) PAGE 2 of 2 Company Name: This page requires the company to report the total sales made in California during the preceding calendar year. Rev. & Tax Code § 30165.1(b)(2)(a). INSTRUCTIONS · · · · Column A: List all Brand Families sold in the preceding calendar year. Indicate by asterick (*) any Brand Family that is no longer being sold in California. Column B: Write "C" after any brand style of Cigarettes, (RYO) after any brand of Roll-Your-Own tobacco, and "LC" after any brands of Little Cigars. Column C: List the total units sold in California during the preceding calendar year. (1 Unit = an individual cigarette or individual Little Cigar or .09 oz. of RYO.) Column D: If the reporting company is not the manufacturer (i.e. fabricator), provide the name and street address of the manufacturer (i.e. fabricator) of the Brand Family. Attach additional sheets, as necessary, to provide a complete answer. A BRAND FAMILY NAME(S) B PRODUCT TYPE C TOTAL UNITS D MANUFACTURER (i.e. FABRICATOR) NAME & ADDRESS Under penalty of perjury, under the laws of California, I declare that I am authorized to certify, on behalf of the reporting company named above, that all of the information contained in this form is complete and accurate. Signature of Company Officer: Print Company Officer Name: Print Company Officer Title: Date: Phone Number: E-mail Address: American LegalNet, Inc. www.FormsWorkFlow.com Fax No: