GOVERNMENT OF THE DISTRICT OF COLUMBIA Office of the Chief Financial Officer ANNUAL TOBACCO PRODUCT MANUFACTURER CERTIFICATION (See Instructions) Part 1: Tobacco Product Manufacturer Identification Company Name: ________________________________________________________ Street Address: _________________________________________________________ City, State, Country, ZIP: _________________________________________________ Name/Title of Person Completing Certification: _______________________________ ______________________________________________________________________ Telephone: _________________________ FAX: ____________________________ E-mail: _______________________________________________________________ As of the date of this Certification, the Tobacco Product Manufacturer identified above is: (check one) ____ a Participating Manufacturer under the Master Settlement Agreement. ____ a Non-participating Manufacturer in full compliance with the Model Act. Part 2: Sales Year The Sales Year for this Certification is: _________ (Note: the Sales Year is the calendar year preceding the year in which the Certification is due. Complete a separate Certification for each Sales Year.) American LegalNet, Inc. www.FormsWorkFlow.com Part 3: Brand Family Identification All Tobacco Product Manufacturers must complete column A. Only Nonparticipating Manufacturers must complete column B. Attach additional sheets if necessary. A. Brand Family B. Number of Units Sold During Sales Year (Nonparticipating manufacturers only) Non-participating Manufacturers (only): In column A above, indicate with an asterisk any Brand Family that is no longer sold as of the date of this Certification. 2 American LegalNet, Inc. www.FormsWorkFlow.com If there has been another manufacturer during the preceding or current calendar year for any Brand Family listed above, list the Brand Family below and state the other manufacturer's name and address. Attach additional sheets if necessary. A. Brand Family B. Other Manufac- C. Other Manufacturer's Address turer's Name Part 4: Non-participating Manufacturer Certification A. D.C. Registration and/or Agent for Service of Process Is the Non-participating Manufacturer registered to do business in the District of Columbia as a foreign corporation or business entity? (Yes or No) __________ If so, state the most recent date of registration: _______________________________ Is this registration current as of the date of this Certification? (Yes or No) __________ Agent's Name: __________________________________________________________ Agent's Company: ________________________________________________________ Street Address: __________________________________________________________ City, State, ZIP: __________________________________________________________ Telephone: ___________________________ FAX: ____________________________ E-mail: ________________________________________________________________ If the Non-participating Manufacturer is not registered to do business in the District of Columbia, attach a letter or other written documentation from the agent for service of process confirming that it will accept service of process for the manufacturer. 3 American LegalNet, Inc. www.FormsWorkFlow.com B. Qualified Escrow Fund - Financial Institution Name of Institution: ______________________________________________________ Address: _______________________________________________________________ Representative Name: _____________________ Telephone: _____________________ Escrow Account Number: __________________________________________________ D.C. Sub-account Number (if any): __________________________________________ Attach to this Certification a copy of each escrow agreement governing the Qualified Escrow Fund at any time during the preceding or current calendar year, unless a copy of the escrow agreement was attached to a previous Certification. Indicate on each copy the start and end (if applicable) of the time period during which the escrow agreement was in effect. C. Escrow Deposits ­ Preceding and Current Calendar Years State the total amount placed in a Qualified Escrow Fund during preceding calendar year: ______________ State the total amount placed in a Qualified Escrow Fund during the current calendar year (to date): ______________ Listing of Escrow Deposits During Preceding and Current Calendar Years (Attach additional sheets if necessary) Date Amount Deposited Amount Withdrawn or Transferred Balance in Escrow after Deposit For each escrow deposit listed above, attach a statement from the financial institution showing that the deposit was made. 4 American LegalNet, Inc. www.FormsWorkFlow.com D. Complete History of Escrow Withdrawals/Transfers (Attach additional sheets if necessary) Date Amount Withdrawn or Explanation of Withdrawal or Transfer Transferred Part 5. Execution by Authorized Representative As the company representative authorized to make this certification, I state under penalty of perjury that the information contained in this Certification is true and complete. Signature: __________________________________ Date: _______________________ Name and Title (Print or Type): ______________________________________________ ________________________________________________________________________ Mail or deliver the completed Certification to: Tobacco Certifications, Office of the Attorney General for the District of Columbia, 441 4th Street, NW, Suite 650-N 450-N, Washington, DC 20001. 5 American LegalNet, Inc. www.FormsWorkFlow.com