IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 1 of 7 (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 PARTICIPATING MANUFACTURER Certification of Compliance PART 1: TYPE OF CERTIFICATION AND SALES YEAR A. Type of Certification: B. Sales Year: Initial Annual Supplemental 2018 Other Year: PART 2: PARTICIPATING MANUFACTURER (HEREAFTER PM APPLICANT), IDENTIFICATION, AND PERMITS/LICENSES A. PM Applicant 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: For Office Use Only American LegalNet, Inc. www.FormsWorkFlow.com IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 2 of 7 (revised 12/18/2018) B. PM Applicant Licenses/Permits: 1. Attach a copy of the PM Applicant222s current U.S. Treasury, Tobacco Tax Bureau (TTB) permit(s) as a manufacturer and/or as an importer. 2. If the PM Applicant is located in a country other than the United States, provide copies of any manufacturing or importer licenses, certificates, permits or similar documents issued by the country where the manufacturing takes place. 3. If the PM Applicant is located in a country other than the United States and the Cigarettes bear a United States trademark, provide a copy of the trademark holder222s certificate under penalty of perjury that it has not withdrawn consent to import the Cigarettes into the United States as required by 19 U.S.C. 2471681a (c)(3)(A), and a copy of the importer222s certificate under penalty of perjury that the trademark owner has not withdrawn consent to import the Cigarettes into the United States as required by 19 U.S.C. 2471681a (c)(3)(B). PART 3: BRAND FAMILY IDENTIFICATION A. Brand Families PM Applicant Seeks to Certify: 1. Brand Family (Indicate with an asterisk (*) if no longer sold in Idaho) 2. Name and address of Tobacco Product Manufacturer of Brand Family in 2018 if different from PM Applicant 3. For Brand Family listed, name of trademark holder, the contact person of the trademark holder, and the contact person222s mailing address and telephone number Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco American LegalNet, Inc. www.FormsWorkFlow.com IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 3 of 7 (revised 12/18/2018) 1. Brand Family (Indicate with an asterisk (*) if no longer sold in Idaho) 2. Name and address of Tobacco Product Manufacturer of Brand Family in 2018 if different from PM Applicant 3. For Brand Family listed, name of trademark holder, the contact person of the trademark holder, and the contact person222s mailing address and telephone number Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Brand Family: Check one: Cigarette RYO tobacco Attach additional sheets as necessary. B. Packaging Samples (check one): Initial certification: Samples of the actual packaging and labeling for each Brand Family (without tobacco) the PM Applicant seeks to certify are attached. American LegalNet, Inc. www.FormsWorkFlow.com IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 4 of 7 (revised 12/18/2018) Annual certification227no new packaging: Samples of the actual packaging and labeling for each Brand Family the PM Applicant seeks to certify in the current year have been previously provided and continue to be current, in effect, and operative. Annual certification227new packaging: Changes in the packaging or labeling have occurred for one or more of the Brand Families the PM Applicant seeks to certify in the current year and the new packaging and labeling for each such Brand Family (without tobacco) are attached. Supplemental certification: Samples of the actual packaging and labeling for each Brand Family the PM Applicant seeks to certify in the current year (without tobacco) are attached. C. Federal Requirements: For each Brand Family (cigarettes only) the PM applicant seeks to certify, attached is a copy of the current Centers for Disease Control (CDC) letter approving the brand222s ingredient listing. Ingredient reporting submitted to CDC by: Relationship to Manufacturer: For each Brand Family (cigarettes only) the PM applicant seeks to certify, attached is a copy of the current Federal Trade Commission (FTC) health-warning rotation plan approval letter. Health warning rotation plan submitted to FTC by: Relationship to Manufacturer: PART 4: SALES AND DISTRIBUTION INFORMATION A. Sales Information (check as applicable): The PM Applicant: 1. Directly, or indirectly through distribution, had Cigarettes sold, offered for sale, possessed for sale, acquired, transported, imported or caused to be imported to or in Idaho in 2018. Yes No 2. Advertised or sold, or intends to advertise or sell, Cigarettes via the Internet or in catalogs and uses the mail or other delivery service to deliver Cigarettes to Idaho consumers. Yes No 3. Seeks to certify a Brand Family for which there has been a change in the manufacturer of the Brand Family in the past two calendar years. Yes No 4. Seeks to certify a Brand Family for which PM Applicant has one or more Brand Families or brand styles manufactured by a different manufacturer. Yes No 5. Directly, or indirectly through distribution, had Cigarettes sold, offered for sale, possessed for sale, acquired, transported, imported or caused to be imported onto, or through an Idaho Stamping Agent who sells, offers for sale, transports or imports onto, an Indian Reservation located in Idaho. Yes No American LegalNet, Inc. www.FormsWorkFlow.com IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 5 of 7 (revised 12/18/2018) If you answered Yes to any of the inquiries in Part 4.A., set forth on separate sheets of paper explanation(s) of the details relating to your affirmative response. B. Distribution Information: Identify the name and address of every Idaho Stamping Agent that sold, offered for sale, possessed for sale, acquired, transported, imported or caused to be imported to or in Idaho in 2018, each Brand Family listed in part 3.A. If you had no such activity to report in 2018, identify the name and address of your designated Idaho Stamping Agent(s). 1 . Brand Family 2 . Idaho Stamping Agent 3 . Street address , mailing address and telephone number of Idaho Stamping Agent Attach additional sheets as necessary. American LegalNet, Inc. www.FormsWorkFlow.com IDAHO PARTICIPATING MANUFACTURER CERTIFICATION OF COMPLIANCE Page 6 of 7 (revised 12/18/2018) C. Importers and Bonded Warehouses: Identify the name and address of all of PM Applicant222s Importer(s) and Bonded Warehouse(s) located in the United States for the Brand Families listed in Part 3.A. 1 . Brand Family 2 . Importer 3 . Street address , mailing address, and telephone number of Importer 4. Street address, mailing address, telephone number and contact name of Bonded Warehouse(s) Attach additional sheets as necessary. PART 5: AUTHORIZED DESIGNEE SIGNATURE AND CERTIFICATIONS The PM Applicant certifies that (initial all): 1. Representation. Under penalty of perjury, PM Applicant222s Authorized Designee certifies and declares that all of the statements and information contained in this Certification, 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 PM Applicant under either the laws of the State of Idaho or of the jurisdiction where the PM Applicant resides or is organized. Any violation of these requirements or these representations is a basis for removal of the PM Applicant and/or its Brand Families from the Directory. 2. Brand Families. The PM Applicant certifies that the Brand Families listed herein is a complete list of all of its Brand Fami