20 1 8 Delaware Quarterly Certificate of Nonparticipating Tobacco Product Manufacturer Compliance 1. Name: 2. Street ad dress: 3. City, state, country, ZIP: 4. Telephone number: 5. Electronic mail address: Part 2: Liability Year/Quarter 6. The liability year for this certificate is: 20 1 8 , Q Part 3: Units Sold 7. Number of individual cigarettes sold by the manufacturer identified above during the liability quarter bearing Delaware cigarette tax stamps is as follows(list amounts by brand ): 1)2) 3) 4) 5)Total sticks: Part 4: Deposit Amount For the liability year 20 1 8 , the base rate per c igarette is $ 0. 0188482 8. The appropriate rate for the liability year as adjusted for inflation* is: 8 . 0.0 347539 9. Multiply Line 8 by total of Line 7, and write the amount ( Total Escrow Payment d ue for the quarter ): 9 . This is your total amount due to be paid in to the qualified escrow account. Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the inst itution if you have not previously provided one or if it has been amended. Part 5: Financial institution 10. Name: 11. Street address: 12. City, state, country, ZIP: 13. Escrow account number 14. Total amount he ld in this account after current deposit: $ 15. Escrow agent: 16. Phone Number: Part 6: Authorized Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. Sworn to and subscribed be fore me Print the name of authorized agent Title this day of , 20 1 8 Signature of Notary Public Signature of authorized agent Date City / State: My commission expires // * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. Quarterly deposits are due 30 days after the end of the calendar quarter. This form is due 10 days after the deposit due date and may be sent to: State of Delaware, Office of Attorney General, Department of Justice, Carvel Office Building, 820 N. French Street, 5 th Fl , Wilmington, DE 19801 , (Attention: Thomas E. Brown , Deputy Attorney General). American LegalNet, Inc. www.FormsWorkFlow.com