Updated 02122018 State of Delaware Department of Justice CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) 226 INSTRUCTIONS JUS-TPM1 Page 1 of 14 Initial Annual Supplemental Sales Year: 20 18 PLEASE TYPE OR PRINT IN PERMANENT BLUE INK PART I: GENERAL BUSINESS AND OWNERSHIP INFORMATION 1. Applicant Tobacco Product Manufacturer Identification Applicant: Street Address: Mailing Address (if different from above): Phone Number: Facsimile (FAX) Number: E-Mail Address: Website Address: Name/Title of Person Completing Certification: Manufacturing Plant(s) Name and Street Address (if different from above): Manufacturing Plant Phone Number: Manufacturing Plant Facsimile (FAX) Number Name/Title/Phone Number of Person at Plant if different from above: (Attach additional sheet(s), as necessary, to provide a complete response) Please attach a photograph or diagram of your manufacturing facility and indicate on the photograph or diagram where the equipment and facilities for manufacturing (i.e., fabricating) the Cigarettes, if any, are located. 2. The undersigned certifies that as of the date of this Certification, the above226named applicant is: (initial one) American LegalNet, Inc. www.FormsWorkFlow.com Updated 02122018 State of Delaware Department of Justice CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) 226 INSTRUCTIONS JUS-TPM1 Page 2 of 14 a Participating Manufacturer (PM). (If applicant is a PM, it may skip the remainder of Part I and go directly to Part II.) a Non-Participating Tobacco Product Manufacturer (223NPM224) in full compliance with Delaware222s statutes including having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales. 3. Applicant is the manufacturer (i.e., fabricator) of the brands listed in this Certification which are intended to be sold in the United States, including Cigarettes intended to be sold in the United States through an importer. Yes No 4. Applicant is the first purchaser anywhere for resale in the United States of Cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. Yes No If the answer is 223Yes,224 identify each Cigarette manufacturer, (i.e., fabricator), its plant street address, mailing address, contact person, telephone, facsimile phone numbers, and the relationship applicant. Identify the location of the transfer of ownership of Cigarettes and a copy of every agreement or contract between applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is a successor of an entity described in questions 3 or 4 above (i.e., manufacturer or first importer). Yes No 6. If applicant answered 223no224 to questions 3, 4, and 5 above, explain the basis for applicant222s claim that it is a Tobacco Product Manufacturer as defined under Section 6081(i) of Title 29 of the Delaware Code and submit all documentation to support applicant222s contention. Attach additional sheet(s), as necessary, to provide a complete response. American LegalNet, Inc. www.FormsWorkFlow.com Updated 02122018 State of Delaware Department of Justice CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) 226 INSTRUCTIONS JUS-TPM1 Page 3 of 14 7. Licenses/Permits: Division of Revenue for the State of Delaware, License Number as tobacco product seller: Please list any additional licenses obtained from the DOR and their numbers: Attach copies of all current and valid licenses from the DOR. b. U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: and/or an importer: Attach a copy of applicant222s current permit as a manufacturer or importer pursuant to 26 USC Chapter 52, and regulations issued thereunder. PART II: BRAND FAMILY IDENTIFICATION 1. Brand Family Identification (PMs complete column A; NPMs complete columns A through C) A. BRAND FAMILY (Indicated with an asterisk (*) those brands that will not be sold in 201 8 ) B. Units Sold in Preceding Calendar Year C. Manufacturer of Brands Listed (Include complete address information) Attach additional sheet(s), as necessary, to provide a complete response. Provide a CD displaying each brand of cigarettes that applicant intends to sell in Delaware. 2. Trademark Holder (If applicant is a PM, it may skip Question 2 and go directly to DECLARATION, ACKNOWLEDGEMENT AND SIGNATURE, page 14.) Provide the name, address, phone number of the trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical address Phone American LegalNet, Inc. www.FormsWorkFlow.com Updated 02122018 State of Delaware Department of Justice CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) 226 INSTRUCTIONS JUS-TPM1 Page 4 of 14 Attach additional sheet(s), as necessary, to provide a complete response. PART III: ADDITIONAL BUSINESS INFORMATION 1. Organizational Documents to Be Attached (See Instructions for list of documents required by this question) 2. Company Officers & Owners Complete the table by listing all company officers and company owners (all Persons with an equity interest of 10% or more in applicant company.) Attach additional sheet(s), as needed, to provide a complete response. 1. CHECK APPROPRIATE TITLE President Partner Other Vice Pres. Partner Other Secretary Partner Other Treasurer Partner Other 2. Full Name (first, middle, last) 3. Street Addr ess 4. Telephone # and Facsimile # 5. Date and Place of Birth 6. E - mail Address 3. Affiliates (see Instructions for further information) Attach additional sheet(s), as necessary, to provide a complete response. Brand Family Affiliate N ame Type of Business Affiliate: Street Address 4. Applicant Information Please indicate whether the following statements describe applicant by circling either yes or no after the statement. a. Applicant sold Cigarettes in Delaware in the preceding calendar year. YES NO b. Applicant made escrow deposits pursuant to Delaware Statute (29 Del. C. Ch. 60C) in the preceding year. YES NO American LegalNet, Inc. www.FormsWorkFlow.com Updated 02122018 State of Delaware Department of Justice CERTIFICATION FOR LISTING ON DELAWARE DIRECTORY (TITLE 29, CHAPTER 60D of the DELAWARE CODE) 226 INSTRUCTIONS JUS-TPM1 Page 5 of 14 c. Applicant sold in the preceding calendar year one or more of the Brand Families listed in this Certificate. YES NO d. Applicant made escrow deposits in the preceding calendar year pursuant to state law for one or more of the Brand Families listed in the Certification. YES NO e. There has been a change in manufacturer (i.e., fabricator) of one or more of the Brand Families listed in this Certification within the past two calendar years. YES NO f. Applicant advertises or sells Cigarettes via the internet or in catalogs or uses the mail or other delivery service to deliver Cigarettes to Delaware consumers. YES NO g. Applicant failed to timely comply with the Delaware Statute, 29 Del. C. Ch. 60C, prior to the establishment of the Directory, or at any time thereafter. YES NO h. Applicant or one of its Brand Families listed in this Certificate was previously denied listing on the Directory or was removed from the Directory. YES NO i. Applicant is enjoined or banned from selling any Cigarettes by court order, state or federal agency ruling or determination. YES No j. A Brand Family formerly sold by applicant or a Brand Family that applicant intends to sell is enjoined from sale by a state court, state agency or a federal court. YES NO k. A state or federal court has entered a judgment finding that applicant engaged in an unfair business practice or unfair competition relating to the sale of tobacco products. YES NO l. Applicant failed to timely file any completed form or document required by the laws of this State. YES NO PART IV: MARKETING AND DISTRIBUTION INFORMATION 1. Tobacco Products Reclassified as Cigarette or RYO Tobacco List all tobacco products sold by applicant that have been reclassified within the last two years as cigarettes or as roll-your-own (RYO) tobacco by a fe