STATE OF GEORGIA TOBACCO PRODUCT MANUFACTURER’S ANNUAL CERTIFICATION Pursuant To O.C.G.A. § 10-13A-3 For 2010 ----------------------------- and ----------------------------- Request For Listing In Georgia Directory Of Compliant Tobacco Product Manufacturers In 2011 Who is required to file this Certification? Any tobacco product manufacturer that sells, intends to sell or has sold cigarettes within the state of Georgia, whether directly or through any distributor, retailer, or similar intermediary, including manufacturers that are participants in the Master Settlement Agreement. You are required to submit this annual certification even if you submitted quarterly certifications during the 2010 sales year or had no sales during the 2010 sales year. Definitions: (a) “Brand Family” means all styles of Cigarettes sold under the same trade mark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, “menthol,” “lights,” “kings,” and “100s,” and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of Cigarettes. (b) “Cigarette” means any product that contains nicotine, is intended to be burned or heated under ordinary conditions of use, and consists of or contains (A) any roll of tobacco wrapped in paper or in any substance not containing tobacco; or (B) tobacco, in any form, that is functional in the product, which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette; or (C) any roll of tobacco wrapped in any substance containing tobacco which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette described in clause (A) of this definition. The term “cigarette” includes “roll-yourown” tobacco. 0.09 ounces of “roll-your-own” tobacco constitutes one individual cigarette. (c) “Directory” means the Attorney General’s list of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming FORM AG-03 (Rev 03/11) 1 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com to the requirements of O.C.G.A. § 10-13A-3 and all Brand Families that are listed in such certifications. (d) “Qualified Escrow Fund” means an escrow fund established pursuant to an escrow agreement that has been approved by the Attorney General as being in compliance with OCGA § 10-13A-2(9). (e) “Tobacco Product Manufacturer” means an entity that physically manufactures cigarettes anywhere in the world that are intended for sale in the United States, either directly or through an importer; an entity that is the first purchaser of cigarettes that the manufacturer did not intend to be sold in the United States, regardless of where those cigarettes were manufactured; or an entity that becomes a successor to an entity described above. (f) “Unit” means one cigarette or .09 ounces of “roll your own” tobacco, as defined above. When is the escrow deposit due? The escrow deposit is due on Friday, April 15, 2011. When is this Certification due? This Certification must be received by us no later than Monday, May 2, 2011. Where do I send this Certification? The Certification must be delivered to two places: Consumer Interests Section Office of the Attorney General 40 Capitol Square Atlanta, Georgia 30334 Georgia Department of Revenue Alcohol and Tobacco Tax Division 1800 Century Center Boulevard Atlanta, Georgia 30345-3205 And INSTRUCTIONS Part 1: Manufacturer's Identification Enter your name, address, telephone, fax number, electronic mail address, and internet address. If you are located in the U.S., provide your federal tax identification number and TTB Tobacco Manufacturer Permit number. Part 2: Certification Type Check whether this is an initial certification (if you are not currently listed), annual certification (due May 2, 2011 for 2010 sales), or supplemental certification (change of information previously provided). FORM AG-03 (Rev 03/11) 2 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com Part 3: A. Brand Family Identification List by Brand Family all of the cigarettes that you sold or intend to sell in Georgia, whether directly or through any distributor, retailer, or similar intermediary and the number of individual cigarettes (units) sold in 2010 and 2011 to date. Only the brands you list will be included in the Directory. It is unlawful to offer for sale in Georgia any cigarette that is not compliant with the Georgia Fire Safety Standard & Firefighter Protection Act, O.C.G.A. § 24-4, et seq. (“fire safe” cigarette act). Accordingly, do not list a brand family unless the required information has been submitted to the Georgia Fire Safety Commissioner and required package markings approved. Participating Manufacturers shall include a list of their Brand Families. A Participating Manufacturer may not include a Brand Family in its certification unless it affirms that the Brand Family is deemed to be its cigarettes for purposes of calculating its payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. The Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General and the Department of Revenue. Non-Participating Manufacturers shall include the following in their certification: a list of all of its Brand Families, and the number of units for each Brand Family that were sold in Georgia during the preceding calendar year; a list of all of its Brand Families that have been sold in Georgia at any time during the current calendar year; indicate, by an asterisk (*), any Brand Family sold in Georgia during the preceding calendar year that is no longer being sold in Georgia as of the date of such certification; and identify the fabricator of the Brand Families. A Non-Participating Manufacturer may not include a Brand Family in its Certification unless it affirms that it is the tobacco product manufacturer of the Brand Family and the Brand Family is to be deemed its Cigarettes for purposes of O.C.G.A. § 10-13-1, et seq. A Non-Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General and Department of Revenue. B. Identify for each Brand Family the name and address of any other fabricator of such Brand Family (either current or past fabricator). For each fabricator identify the time period during which the party fabricated the brand. FORM AG-03 (Rev 03/11) 3 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com C. Factory Identification: Enter the name, owner, address, phone and fax number of the factory that currently fabricates the cigarettes or RYO tobacco listed. Part 4: Non-Participating Manufacturer Certification Each Non-Participating Manufacturer must: A. Appoint an agent for service of process and complete and submit Form AG-02 (NPM’s Appointment of Registered Agent & Registered Agent’s Statement Form.) The agent for service of process listed in this section must be the same as the agent appointed in Form AG-02. B. State the name, address and telephone number of the financial institution where the Non-Participating Manufacturer has established a Qualified Escrow Fund pursuant to O.C.G.A. § 10-13-3(2) and the account number of such Qualified Escrow Fund and any sub-account number for Georgia; Please attach a copy of your Escrow Agreement with all amendments, unless a current copy is already on file with our office. Part 5: Non-Participating Manufacturer Escrow Deposit Calculation A. The liability year for this certificate is the 2010 calendar year: January 1, 2010 through December 31, 2010. B. List the number of units sold during the liability year bearing Georgia tax stamps by brand and the total number of cigarettes sold. C. Calculate the deposit, subtracting all amounts deposited into your qualified escrow account during the 2010 sales year for sales made in 2010. The amount on Line C(5) is the amount that must be deposited into a qualified escrow account by April 15, 2011. D. Identify (i) the amount you placed in such fund for units sold in Georgia during 2010 and each preceding year, the date and amount of each such deposit, and the total account balance; and (ii) the amount and date of any withdrawal or transfer of funds you made at any time from such fund or from any other Qualified Escrow Fund. Attach a copy of your receipt or other proof of deposit for 2010 sales from your financial institution and a bank statement showing the current account balance. Part 6: Execution by Authorized Designees The person executing the Certification must be an authorized representative of the Tobacco Product Manufacturer FORM AG-03 (Rev 03/11) 4 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com identified in Part 1. The Designee’s name and title must be legibly printed and the Certification must be executed in the presence of an authorized notary. You may send any questions about this form by mail or facsimile to: Consumer Interests Section Office of the Attorney General • 40 Capitol Square SW • Atlanta GA 30334 Facsimile 404.656.0677 FORM AG-03 (Rev 03/11) 5 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF GEORGIA TOBACCO PRODUCT MANUFACTURER’S CERTIFICATION Pursuant To O.C.G.A. § 10-13A-3 For 2010 ----------------------------- and ----------------------------- Request For Listing In Georgia Directory Of Compliant Tobacco Product Manufacturers In 2011 Part 1: Tobacco Product Manufacturer Identification Company:_________________________________________________________________ Address:__________________________________________________________________ Address:__________________________________________________________________ Phone: ______________________________ FAX: ______________________________ Email: ______________________________Web Address: _________________________ Name/Title of person completing report: _________________________________________ If located in the U.S.: Manufacturer’s Federal I.D. # : ______________________________ If located in the U.S.: TTB Tobacco Manufacturer Permit Number: ___________________ The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (check one) ‰ A Participating Manufacturer under the Tobacco Master Settlement Agreement who is generally performing its financial obligations under the Tobacco Master Settlement Agreement. ‰ A Non-Participating Tobacco Product Manufacturer in full compliance with O.C.G.A. § 10-13-1, et seq. Part 2: Certification Type This form is a (check one): Ƒ Initial certification – Manufacturer is not currently listed on the Georgia Directory of Compliant Tobacco Product Manufacturers Ƒ Annual certification – Due May 2, 2010 for sales made in Georgia in 2010 Ƒ Supplemental certification – Change of information previously provided. Change of information must be submitted 30 days prior to change. FORM AG-03 (revised 03/11) Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com Part 3: A. Brand Family Identification (Attach additional Sheets if Necessary) Participating Manufacturers complete A & B; Non-Participating Manufacturers complete A through E. A. Brand Family Indicate with an asterisk (*) those brands no longer being sold in Georgia. B. Cigarette or RYO C. Units Sold in 2010 (.09 oz of RYO equals 1 unit) D. Units Sold in 2011 (.09 oz of RYO equals 1 unit) E. Fabricator Note: By including a brand family in its certification, a Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of calculating its payments under the MSA for the 2010 and 2011 sales years. By including a brand family in its certification, a Non-Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for escrow purposes for the 2010 and 2011 sales years. However, the Attorney General retains the discretion to determine whether the listed brand family is actually the cigarette of another tobacco product manufacturer. It is unlawful to offer for sale in Georgia any cigarette that is not compliant with the Georgia Fire Safety Standard & Firefighter Protection Act, O.C.G.A. § 24-4, et seq. (“fire safe” cigarette act). Do not submit a brand family for listing unless the required information has been submitted to the Georgia Fire Safety Commissioner and required package markings approved. B. For each brand family listed above, list the name and address of any other manufacturer who has fabricated or is currently fabricating the brand family. C. Factory Identification Name of Factory: ____________________________ Phone Number: _________________ Owner of Factory: ____________________________ Fax Number: ___________________ Address of Factory: _________________________________________________________ FORM AG-03 (revised 03/11) Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com Part 4: A. Non-Participating Manufacturer Certification Registered Agent / Approved Agent for Service of Process Agent Name: ______________________________________________________________ Company:_________________________________________________________________ Address (including county): __________________________________________________ Address:__________________________________________________________________ Phone: ___________________________________ FAX: __________________________ Email: ____________________________________________________________________ Complete and submit an Appointment of Registered Agent for the State of Georgia and Registered Agent’s Statement form. (Form AG-02) B. Qualified Escrow Fund – Financial Institution Name of Institution: _________________________________________________________ Address:__________________________________________________________________ Representative: ____________________________________________________________ Phone: ___________________________________________________________________ Escrow Acct No:_______________________ Georgia Sub-Account No: ______________ Attach an executed copy of your Escrow Agreement with all amendments and attachments, unless a current copy is already on file with our office. Part 5: Non-Participating Manufacturer Escrow Deposit Calculation A. Liability Year: The liability year for this certificate is January 1, 2010 through December 31, 2010. B. Units Sold: The number of individual cigarettes or units of RYO sold in Georgia in 2010 by brand is: Brand Name: Brand Name: Brand Name: Brand Name: ____________________ ____________________ ____________________ ____________________ Number of units sold: Number of units sold: Number of units sold: Number of units sold: __________________ __________________ __________________ __________________ Total: __________ FORM AG-03 (revised 03/11) Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com C. Calculating the Deposit Amount Follow these steps to calculate the appropriate amount to be deposited for the liability year 2010 (1) Enter the total number from Part 5 Section B above: ________________ (2) Multiply that amount by .0274350 which is the combined 2010 Base Amount and Inflation Adjustment: x (3) Enter the total here: _________________ .0274350 (4) Enter the total amount deposited into escrow for 2010 sales during the 2010 sales year: (5) Subtract line (4) from line (3), enter the total here: The amount that must be deposited on or before April 15, 2011 for the liability year 2010 will be the amount shown in Line C(5). D. Date Escrow Deposit/Withdrawal History for Georgia Deposit Withdrawal Balance Withdrawals must comply with O.C.G.A. § 10-13-3-(2)(B). Verification of compliance must be provided Attach a copy of your receipt or other proof of deposit for 2010 sales from your financial institution. & Attach a copy of bank statement showing the current account balance Part 6. Execution by Authorized Designee This certification must be signed by a qualified company officer authorized to bind the applicant company. By executing this document, I confirm that my position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. FORM AG-03 (revised 03/11) Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com I understand the Georgia Attorney General may require additional information and/or documentation to determine if the applicant company or brands are in compliance with Georgia law and qualify for the Georgia Directory. Under penalty of perjury, I state that the information contained in this Certification and attachments is true and accurate. Designee (Print Name): _____________________________ Title: _______________________ Signature of Designee: _____________________________ Date: ______________________ Subscribed and sworn to before me on this date: ______________________________________ Signature of Notary Public: __________________________ City or County of: ____________ My Commission expires: ____________________________ Mail the completed certificate of compliance to: Consumer Interests Section Office of the Attorney General 40 Capitol Square Atlanta, Georgia 30334 FORM AG-03 (revised 03/11) And Georgia Department of Revenue Alcohol and Tobacco Tax Division 1800 Century Center Boulevard Atlanta, Georgia 30345-3205 Doc # 620592 American LegalNet, Inc. www.FormsWorkFlow.com