Page 1 of 7 Certification Form (revised January 2018) STATE OF HAWAI221I Department of the Attorney General Tobacco Enforcement Unit Certification For Hawai221i Tobacco Directory Pursuant to Haw. Rev. Stat., Chapters 245 and 486P For Cigarettes and Roll-Your-Own (RYO) Tobacco Initial Certification Annual Certification Supplemental Certification Part I Tobacco Product Manufacturer1 Identification Name: Address: Telephone: Facsimile: Website: Contact: Email: Manufacturing plant(s) name and address (if different from above): The Tobacco Product Manufacturer identified above is, as of the date of this certification: (check one box ) A Participating Manufacturer (PM) under the Master Settlement Agreement (MSA). A Non-Participating Manufacturer (NPM) in full compliance with Haw. Rev. Stat. 247675-3(b). The Tobacco Product Manufacturer identified above has: (this box must be checked ) Complied with its quarterly reporting requirements pursuant to Haw. Rev. Stat., 247486P-2(a). Part II Calendar Year (Provide a separate certification for each year.) 2018 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Certification Form (revised January 2018) Part III Brand Family Identification (Attach additional sheet(s), as needed, to provide complete response.) 1. The PM identified in Part I has the following Brand Families, each of which the manufacturer hereby affirms are to be deemed its Cigarettes2 for purposes of calculating its payments under the MSA for the relevant year, in the volume and shares determined pursuant to the MSA. List each Brand Family including all 223styles224; a Brand Family will be assumed to be cigarettes unless designated as RYO. Brand Family (indicate with an asterisk (*) those brands that will not be sold in 2018) 2. The NPM identified in Part I has the following Brand Families, each of which the manufacturer hereby affirms are to be deemed its Cigarettes3 for purposes of Haw. Rev. Stat., Chapter 675 for the relevant year. List each Brand Family including all 223styles224; a Brand Family will be assumed to be cigarettes unless designated as RYO. Attach a sample of the actual packaging for each brand of Cigarette and RYO to be listed in the Directory. A. Brand Family (indicate with an asterisk (*) those brands that will not be sold in 2018) B. Units Sold in preceding calendar year C. Manufacturer of brands listed (include complete address information) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 Certification Form (revised January 2018) Part IV Non-Participating Manufacturer's Additional Information 1. Company Officers and Owner(s) Identification. List all company officers and owners (all persons with an equity interest of 10% or more in the applicant company). Attach additional sheet(s), as needed, to provide complete response. President : Owner Address: % interest Partner Email: Vice President : Owner Address: % interest Partner Email: Secretary : Owner Address: % interest Partner Email: Treasurer : Owner Address: % interest Partner Email: Other : Owner Address: % interest Partner Email: 2. Applicant Information. Indicate whether the following statements describe applicant by marking the box 223yes224 or 223no224 after the statement. Yes No A. Applicant sold (whether directly or through a distributor, retailer or similar intermediary or intermediaries) Cigarettes to consumers within the State of Hawai221i in the preceding calendar year. B. Applicant placed moneys into a Qualified Escrow Fund pursuant to Chapter 675 for its sales in the preceding calendar year. C. There has been a change in manufacturer (i.e., fabricator) for one or more of the brands listed in this certification within the past two calendar years. D. Applicant sells Cigarettes via the Internet or direct mail order to consumers within the State of Hawai221i. American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7 Certification Form (revised January 2018) 3. Registered Agent for Service of Process. Please certify as follows: (check one ) The NPM identified in Part I is domiciled in the State of Hawai221i. The NPM identified in Part I is a non-resident or foreign NPM that has registered to do business in the State of Hawai221i as a foreign corporation or business entity. The NPM identified in Part I has appointed and continues to engage the following agent located in the United States for service of process on whom all process, any action or proceeding against it concerning or arising out of the enforcement of Haw. Rev. Stat., Chapters 486P or 675, may be served in any manner authorized by law. (Proof of appointment and availability must be submitted directly from agent. ) Name of Agent: Address: Telephone: Facsimile: Email: 4. Qualified Escrow Fund 226 Financial Institution. Name of Institution: Address: Telephone: Facsimile: State Sub-Account No: Escrow Account No: Contact Person: Email: (Attach an executed copy of current escrow agreement along with Attachment A listing Hawai221i.) 5. Escrow Deposit/Withdrawal History for Hawai221i. (Attach additional sheet(s) as needed.) Date Deposit* Withdrawal* Balance * Amounts must comply with Haw. Rev. Stat., Chapter 675. American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 7 Certification Form (revised January 2018) 6. Health Warning Rotation Plan. For each Brand Family, list the name and address of the entity that filed a Cigarette Health Warning Rotation Plan with the Federal Trade Commission (FTC) before the Cigarettes were distributed into the United States. A. Brand Family B. Filer C. Street Address For each Brand Family, attach the FTC222s written approval of applicant222s annual Cigarette Health Warning Rotation Plan. Attach additional sheet(s), as needed, to provide a complete response. 7. Tobacco Ingredient Reporting. For each Brand Family, list the name and address of the entity that submitted the Tobacco Ingredient Reporting information to the Secretary of the U.S. Department of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act (FCLAA) (15 U.S.C. 2471335a(a)). A. Brand Family B. Submitter C. Street Address For each Brand Family, attach copies of all Certificates of Compliance received from the Center for Disease Control and Prevention for applicant222s annual Tobacco Ingredient Reporting required by the FCLAA. Attach additional sheet(s), as needed, to provide a complete response. 8. Imported Cigarettes; Documentation and Verification. If the Cigarettes applicant sells or intends to sell are not made in the United States, provide the documents listed below: A. A copy of the importer permit issued pursuant to 26 U.S.C. 2475713 to the person importing the Cigarettes into the United States; and B. A copy of the certificate, required by 19 U.S.C. 2471681a(c)(1), signed by the NPM of such Cigarettes that such NPM will timely submit to the Secretary of the U.S. Department of Health and Human Services the Tobacco Ingredient Reporting information required by 15 U.S.C. 2471335a(a); and C. A copy of the certificate, required by 19 U.S.C. 2471681a(c)(2), signed by the importer regarding the precise format of warnings and the rotation plan for health warnings; and D. A copy of the certificate, required by 19 U.S.C. 2471681a(c)(3)(A), signed by the U.S. trademark holder that it consents to the importation of such Cigarettes into the United States; and E. A copy of the certificate, required by 19 U.S.C. 2471681a(c)(3)(B), signed by importer that the consent referred to in 19 U.S.C. 2471681a(c)(3)(A) is accurate, remains in effect, and has not been withdrawn. F. The complete address of the factory at which the Cigarettes are fabricated. Name: Address: (Identify the factory that fabricates each Brand Family; attach additional sheet(s), as needed.) American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 7 Certification Form (revised January 2018) 9. Trademark Owner; Cigarette and Roll-Your-Own Tobacco Brands. Submit a list of trademark owners for those brands of cigarettes and roll-your-own tobacco listed in Part III(2). Those brands for which the trademark owner is other than the applicant, documentation that shows the trademark owner authorizes applicant to