IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES Page 1 of 3 (revised 12/18/2018) OFFICE OF THE ATTORNEY GENERAL Lawrence G. Wasden Consumer Protection Division 954 W. Jefferson, 2nd Floor P.O. Box 83720 Boise, ID 83720-0010 Phone: (208) 334-2424 IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES (This form is due April 30, 2019) Please note: If you are a Non-Participating Manufacturer that is required to make quarterly escrow deposits, do not use this form. Instead, use the Idaho Quarterly Certification of Escrow Funding Compliance form. As part of certification, the Idaho Attorney General advised whether the Non-Participating Manufacturer must make quarterly escrow deposits. PART 1: NON-PARTICIPATING MANUFACTURER IDENTIFICATION Company Name: Physical Address: (street address only; no post office box): Mailing Address (if different from above): Phone: FAX: Email Address: Website Address: FEIN: Name of Person Completing Certification: Title: PART 2: SALES YEAR The sales year for this Idaho Certification of Escrow Funding Compliance is the calendar year 2018. Complete this form only for calendar year 2018 sales. For Office Use Only American LegalNet, Inc. www.FormsWorkFlow.com IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES Page 2 of 3 (revised 12/18/2018) PART 3: UNITS SOLD FOR CALENDAR YEAR 2018 Indicate the number of Units Sold (an individual cigarette from a pack that bears an Idaho state cigarette excise tax stamp or .09 ounces of roll-your-own tobacco equals one Unit Sold) by the above-named Non-Participating Manufacturer, whether directly or through a distributor, retailer, or similar intermediary or intermediaries, for the calendar year 2018, and write that amount here: A. PART 4: ESCROW PAYMENT AMOUNT Calculate the appropriate escrow deposit amount. Multiply the number of Units Sold listed in part 3.A. by $0.0347539 and write that amount here.* A. The calculated figure in 4.A. is the amount that must be deposited by April 15, 2019, on behalf of the State of Idaho in the certifying Non-Participating Manufacturer222s Qualified Escrow Fund for calendar year 2018. PART 5: FINANCIAL INSTITUTION/ESCROW INFORMATION Name of Qualified Escrow Fund Financial Institution: Authorized Escrow Agent Contact Name and Title: Physical Address: Mailing Address: Email Address: Phone: FAX: Qualified Escrow Fund Account Number: Qualified Escrow Fund Idaho Subaccount Number: Attached is a copy of the financial institution222s receipt or other proof from the Escrow Agent of the escrow deposit. Pursuant to Idaho Code 24739-8403(1)(c)(iv)(3) the Office of the Attorney General requires verification from the financial institution of the amount and date of deposit to be attached to the Idaho Annual Escrow Certification of Escrow Funding Compliance. PART 6: CERTIFICATION The above-identified Non-Participating Manufacturer certifies that (initial all four): *Idaho Code 247 39-7803(b)(1) requires payments to be 223adjusted for inflation.224 Idaho Code 247 39-7802(a) defines 223adjusted for inflation224 as cumulative increases 223in accordance with the formula for inflation adjustment set forth in Exhibit C to the Master Settlement Agreement.224 Each year, this figure increases 3% or the actual inflation rate, whichever is greater. The adjusted for inflation rate for 2018 is 84.3889%. Multiplying the base escrow deposit amount, $.0188482, by the cumulative adjusted for inflation rate, 84.38819%, equals the cumulative inflation adjustment amount of $.0159057. Adding the base escrow deposit amount, $.0188482, to the cumulative inflation adjustment amount, $.0159057, equals $.0347539. American LegalNet, Inc. www.FormsWorkFlow.com IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES Page 3 of 3 (revised 12/18/2018) It has previously submitted an Idaho Non-Participating Manufacturer Certification of Compliance to the Office of the Attorney General. Date submitted: ; Its Qualified Escrow Fund complies with Idaho Code 247247 39-7802(f) and 39-8403(1)(c); Any escrow funds held or to be held in its Qualified Escrow Fund on behalf of the State of Idaho are or will be held in a separate segregated account, separate and apart from escrow funds held on behalf of any other beneficiary; and There is no property interest, nor security interest as defined by Idaho Code 247 28-1-201(35), that has been granted in or has attached or is otherwise applicable to any escrow funds held or to be held in the above-identified Non-Participating Manufacturer222s Qualified Escrow Fund on behalf of the State of Idaho, nor has the Non-Participating Manufacturer transferred any ownership interest in the Qualified Escrow Fund to any other entity, without first obtaining the prior written consent of the State of Idaho. PART 7: AUTHORIZED DESIGNEE SIGNATURE AND CERTIFICATION Under penalty of perjury, the Non-Participating Manufacturer222s Authorized Designee certifies and declares that all of the statements and information contained in this Idaho Annual Certification of Escrow Funding Compliance for the year being reported, including attachments, if any, are true, correct, accurate and complete in every particular, and that he or she is a person authorized to bind the above-identified Non-Participating Manufacturer either under the laws of the State of Idaho or of the jurisdiction where the Non-Participating Manufacturer resides or is organized. Any violation of these requirements or these representations is a basis for removal of the Non-Participating Manufacturer and/or its Brand Families from the Idaho Directory of Compliant Tobacco Product Manufacturers and Brand Families. Authorized Designee: Title: Signature of Designee: Date: Subscribed and sworn to before me on this date: Signature of Notary Public: City or County of: Printed Name of Notary Public: My Commission expires: Seal: American LegalNet, Inc. www.FormsWorkFlow.com IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES INSTRUCTIONS Page 1 of 3 (revised 12/18/2018) INSTRUCTIONS FOR IDAHO ANNUAL CERTIFICATION OF ESCROW FUNDING COMPLIANCE FOR 2018 SALES General Information Who must file an Idaho Annual Certification of Escrow Funding Compliance? Any Non-Participating Manufacturer whose Cigarettes (including roll-your-own tobacco 226 see Definitions on page 2) are sold in the state of Idaho, whether directly or through any distributor, retailer, or similar intermediary, must execute and deliver an Idaho Annual Certification of Escrow Funding Compliance (Idaho Annual Escrow Certification) to the Office of the Attorney General. An Idaho Quarterly Certification of Escrow Funding Compliance (Idaho Quarterly Escrow Certification) must be executed and delivered quarterly by Non-Participating Manufacturers that meet one of the following criteria: they have not previously established and funded a Qualified Escrow Fund in Idaho; they have not made any escrow deposits for more than one year; they have failed to make a timely and complete escrow deposit for any prior calendar year; they have failed to pay any judgment, including any civil penalty; or they have sold more than 1,600,000 of their Cigarettes during a quarter. Additionally, the Attorney General may require quarterly escrow deposits from a Non-Participating Manufacturer if the Attorney General has reasonable cause to believe the Non-Participating Manufacturer may not make its full required escrow deposit by April 15th of the year following the year in which the Cigarette sales were made. The Idaho Annual Escrow Certification and the Idaho Quarterly Escrow Certification and information about their applicability are located at: www.ag.idaho.gov . Please note: The Idaho Annual Escrow Certification (or the Idaho Quarterly Escrow Certification as applicable) is in addition to Idaho222s Non-Participating Manufacturer Certification of Compliance that all Non-Participating Manufacturers must execute and deliver to the Office of the Attorney General before Cigarettes of the Non-Participating Manufacturer may be sold in the State of Idaho and annually thereafter. The Idaho Annual and Quarterly Escrow