STATE OF CALIFORNIA JUS-TOB3 (Rev. 02/2011) DEPARTMENT OF JUSTICE CERTIFICATION OF COMPLIANCE AND AFFIDAVIT BY NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER REGARDING DEPOSIT OF RESERVE FUNDS INTO ESCROW * PAGE 1 of 2 Year: *If your Company is required to make deposits into escrow more frequently than annually, indicate the specified reporting period for which deposit was made: Quarter ending: Other Period: to Complete a separate Certification of Compliance for each reporting period NOTE TO DISTRIBUTORS: YOU MAY STAMP AND SELL ONLY THE BRANDS OF MANUFACTURERS WHICH 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 Certification 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 Certification of Compliance Must Be Provided to California Distributors and Wholesalers Which Sell Your Product. Part 1: Tobacco Product Manufacturer's Identification* Company Name: Street Address: E-mail Address: Phone Number: Board of Equalization (BOE) Manufacturer's License No.: *All manufacturers (i.e., fabricators) must complete and sign this Certification. Use as many copies of this form as needed. Fax Number: Part 2: Units Sold Total number of individual Cigarettes, including "roll-your-own" tobacco, sold by the manufacturer identified above during the sales period is: (Attach Brand Families Unit Sales Schedule 1 (JUS-TOB4) Part 3: Calculation of Deposit Amount For the sales year: (Use the rates listed below to figure 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 the sales year is ................................................................................. _____________________ Subtotal (Multiply units in Part 2 by the appropriate rate in Part 3) .........................................$_____________________ The Inflation Adjustment according to Exhibit C* of MSA is ....................................................$_____________________ This is the amount that has been paid into the Qualified Escrow Fund by the manufacturer identified above: Total: $_____________________ *See instructions and attached copy of Exhibit C to the MSA PROOF OF DEPOSIT OF THE ABOVE AMOUNT FROM YOUR FINANCIAL INSTITUTION MUST BE ATTACHED. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA JUS-TOB3 (Rev. 02/2011) DEPARTMENT OF JUSTICE CERTIFICATION OF COMPLIANCE AND AFFIDAVIT BY NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER REGARDING DEPOSIT OF RESERVE FUNDS INTO ESCROW PAGE 2 of 2 Part 4: Financial Institution Information Name: Address: Authorized Escrow Agent: Phone Number: Escrow Account Number: Total Funds Held in Separate Account For California: $ Fax Number: Part 5: 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 Certification of Compliance 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. Name (Type or Print): Signature of Authorized Agent: Subscribed and Sworn to Before Me on this Date: Signature of Notary Public: Commission Expires: Name (Type or Print): Title: Date: City of: This form must be filed with the Attorney General's 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