NPM-1 State of Illinois Certification of Non-Participating Manufacturer p. 1 of 4 Please Review Instructions Prior to Completion. Part 1: Liability Year and Type of Certification Liability Year for this Certification: Complete a separate form for each liability year for which you are certifying. (check one) Type of Certification: (check one) Initial Other: 2010 Annual ______ Supplemental Part 2: Manufacturer Identification Company Name FEIN Mailing Address City State Zip Code Phone Fax Country Web Address Name and title of person completing this form Part 3: Brand Family Certification (Attach Brands Addendum pages as necessary) The undersigned manufacturer certifies, under penalty of perjury, as of the date of this certification, it is a Non-Participating Manufacturer (NPM) and is in full compliance with the Escrow Act and the Escrow Enforcement Act of 2003 as well as any regulations and quarterly installment payments. The undersigned NPM certifies that the following list is a complete list of all of its brand families which are to be deemed to be its cigarettes (including RYO product) for purposes of Section 15 of the Escrow Act. Nothing in this certification shall limit or otherwise affect the State’s right to maintain that a brand family constitutes cigarettes or roll-your-own tobacco of a different tobacco product manufacturer for purposes of Section 15 of the Escrow Act. For each brand style that the Fire Marshal has approved and for which the Attorney General’s Office has approved the Brand Family, provide the following information: Brand Style, Size (100 or Kings), Flavor, Filter (y/n) and Package (Soft/Box) as it should be listed on the Illinois Directory. Provide corrections, if any, for the brand style information for FSC cigarettes listed on the Illinois Directory. Include with your certification sample packaging for each brand family named. Packaging for FSC products must be provided when changes are made to the packaging or new products are certified for listing and sale in Illinois. Packaging provided for cigarettes must reflect compliance with the Cigarette Fire Safety Standard Act (425 ILCS §8/1, et seq.). Submit new packaging each time you change your packaging or add new brand families. Report Units Sold in Sticks for Cigarettes and in Ounces for RYO Brand Family Asterisk (*) denotes brands which are no longer sold in Illinois Check One Units Sold in Units Sold in 2010 2011 Check indicates Packaging is Submitted  Name & address of manufacturer of brand family in 2009 if different from NPM identified in Part 2 ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO Total of RYO Ounces Total of Cigarette Sticks American LegalNet, Inc. www.FormsWorkFlow.com NPM-1 State of Illinois Certification of Non-Participating Manufacturer p. 2 of 4 Please Review Instructions Prior to Completion. Part 4: Certification of Escrow Account and Agreement The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account, pursuant to Section 15 of the Escrow Act. Name of Financial Institution (Escrow Agent) Mailing Address City State Zip Code Phone Fax Contact Person Contact E-Mail Escrow Account Number Total amount held in this account for the State of Illinois Illinois Sub-Account Number $ ☐ Yes Are funds held for the benefit of the State of Illinois in any account other than that listed above? ☐ write If you answered “yes,”Yes the total amount of all funds which are being held in any account for the benefit of the State of Illinois, including the amount listed above. Has the Qualified Escrow Agreement been approved by the Attorney General? Attach an executed copy of your current escrow agreement whether or not it has already been approved by the Attorney General. ☐ Yes ☐ No ☐ No $ Date of Agreement: __________________ Approval Date: __________________ Part 5: Worksheet for Cigarettes Sold During Liability Year Total of RYO Ounces from Part 3 Refer to Worksheet at left to calculate the number of individual cigarettes bearing Illinois cigarette tax stamps, including roll-your-own tobacco (.09 ounces = 1 cigarette), which were manufactured by this manufacturer and sold in Illinois during this reporting period. RYO Stick Calculation (Divide RYO Ounces by .09) Liability Year Worksheet is for: Total of Cigarette Sticks from Part 3 2010 Total NPM Sales (Add RYO Stick Calculation to Total of Cigarette Sticks) Part 6: Deposit Amount Other: _____________ Please convert pounds to ounces before using this worksheet. (Multiply by 16.) Use the rates listed below to figure the appropriate deposit amount. For the liability year 2007 and later, the rate per cigarette is . . . . . . . . . . . .0188482 Contact the Tobacco Enforcement Bureau for rates for previous years. 1 Enter the appropriate rate for the liability year. 1 2 Multiply Line 1 by Total NPM Sales (Part 5) and write the amount. 2 3 Multiply Line 2 by the inflation adjustment percentage and write the amount. 3 0.0188482 For 2010 liability period, the inflation adjustment percentage is 45.55773 percent (multiplier of .4555773). Enter the total amount to be paid into the escrow account for this liability year by the manufacturer identified in Part 2 (the total of Lines 2 and 3). 4 $ 5 Enter the total amount paid into the escrow account for this liability year. 5 $ 6 Amount over/under-paid (Difference between Line 4 and Line 5.) Provide explanation if not zero. 6 $ 4 Note: Attach a copy of your receipt or other proof of deposit from your financial institution. American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Certification of Non-Participating Manufacturer NPM-1 p. 3 of 4 Please Review Instructions Prior to Completion. Part 7: Certification of Deposits, Withdrawals and Transfers Attach separate page for each sub-account. The NPM certifies the following to be a complete record of each deposit and withdrawal or transfer which has occurred from any and all accounts containing funds held for the benefit of the State of Illinois. Report ending balances of all such accounts, even where no deposits or withdrawals occurred. Attach copies of records of the financial institution documenting any account activity. Illinois Sub-Account Number Name of Financial Institution (Escrow Agent) Deposit Amount Column Totals $ Withdrawal or Transfer Amount Explanation for Withdrawal or Transfer Deposits Date Withdrawals/Transfers Ending Balance for this Illinois Sub-Account $ $ American LegalNet, Inc. www.FormsWorkFlow.com NPM-1 State of Illinois Certification of Non-Participating Manufacturer p. 4 of 4 Please Review Instructions Prior to Completion. Part 8: Designated Contact Name Title Mailing Address City State Zip Code Phone Fax Country E-Mail Part 9: Manufacturer Certification Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents are true and accurate and that I am a person authorized to bind the manufacturer making this certification either under the laws of the State of Illinois or of the jurisdiction where the manufacturer resides or is organized. I understand that the Attorney General may require additional information and/or documentation to determine whether the manufacturer qualifies for listing on the Illinois Directory. This document must be signed and dated by an authorized notary public. NPM Authorized Designee (Print Name) Title Signature of NPM Authorized Designee Date Subscribed and sworn to before me this date: Signature of Notary Public County Commission Expires Checklist of required documents ☐ NPM-1 Certification of Non-Participating Manufacturer ☐ Qualified Escrow Agreement ☐ NPM-2 Certification of Appointment of Agent for Service of Process ☐ Sample packaging (if required) for each brand family identified in Part 3 ☐ NPM-3 Certification of Additional Information ☐ Proof of Deposit for Part 6 ☐ NPM-F Certification of Additional Information for Foreign NPMs ☐ Bank records confirming deposits, withdrawals or transfers for Part 7 ☐ NPM-PACT Certification of PACT Act Information ☐ Any Brands Addendum pages for Part 3 Brand Family Certification ☐ NPM-S Non-Participating Manufacturer’s Sales Information ☐ Any Accounts Addendum pages for Part 7 Certification of Deposits, Withdrawals and Transfers Mail to Submit the completed certification and other required documentation to the Tobacco Enforcement Bureau at this address: Office of the Illinois Attorney General Tobacco Enforcement Bureau 500 South Second Street Springfield IL 62706 For Additional Forms and Information Phone (217) 785-8541 Fax (217) 524-4701 www.IllinoisAttorneyGeneral.gov (Click on Tobacco.) Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com NPM-1 Instructions for Certification of Non-Participating Manufacturer Instructions General Information What is a Non-Participating Manufacturer? A Non-Participating Manufacturer (NPM) is any cigarette (including RYO) manufacturer who has not signed on to the tobacco Master Settlement Agreement (MSA). Who must file this Certification? Any Non-Participating Manufacturer whose cigarettes or roll-your-own tobacco (RYO) were sold in Illinois during the preceding calendar year or who intend for their brands to be listed as compliant in the Illinois Directory of Compliant NPMs. If a brand is not listed in this certification, it will not be listed in the Directory. It is unlawful to stamp or offer for sale in the State of Illinois any cigarette or RYO brand which is not included in the Illinois Directory of Participating Manufacturers or Directory of Compliant NPMs. Non-Participating Manufacturers will receive written notification when their brands have been deemed compliant for sale in Illinois. Cigarette Fire Safety Standard Act Effective January 1, 2008 certifications must be filed with the Illinois State Fire Marshal and a copy sent to the Attorney General. Packaging for cigarettes must be provided when changes are made to the packaging or new FSC products are certified and must reflect compliance with the Cigarette Fire Safety Standard Act (425 ILCS §8/1, et seq.). Provide a copy of the approval letter from the Illinois State Fire Marshal, as well as a list of brand styles that have been approved or are pending approval. The list should include: brand style, size (100 or king), flavor, filter (y/n), and package (soft/box) as it should be listed on the Illinois Directory. Where do I send my completed Certification? Mail this completed Certification (NPM-1), the NPM-2 form (Certification of Appointment of Agent for Service of Process), the NPM-3 (Certification of Additional Information),NPM-F (Foreign NPM Additional Information), NPM-PACT (Certification of PACT Act Information), NPM-S (Non-Participating Manufacturer’s Sales Information) and related documents to: What is a qualified escrow fund? An escrow arrangement with a U.S. federal or U.S. state chartered financial institution having no affiliation with any Tobacco Product Manufacturer and having assets of at least one billion dollars ($1,000,000,000) where such arrangement requires that the financial institution hold the escrowed funds’ principal for the benefit of Releasing Parties and prohibits the Tobacco Product Manufacturer placing the funds into escrow from using, accessing or directing the use of the funds’ principal except as consistent with the applicable NPM Statutes. Office of the Illinois Attorney General Tobacco Enforcement Bureau 500 South Second Street Springfield, IL 62706 Specific Instructions Part 1: Liability Year and Type of Certification All funds shall be held by the Escrow Agent in sub-accounts separate and apart from all other funds and sub-accounts of each Beneficiary State. • When must I make my escrow payment? • • Check appropriate liability year. You must submit a separate certification for each year. If “Other” is checked, enter liability year for which certification is being provided. Check whether this is an initial (manufacturer is not currently listed on the Illinois Directory), annual (due April 30, 2011 for 2010 sales) or supplemental (change of information provided to the Attorney General) certification. You must deposit all escrow payments into your qualified escrow fund on or before April 15 each year. After you have made your deposit, provide a copy of your receipt or other proof of deposit from your financial institution, along with your escrow agreement, any amendments and this certification. Part 2: Manufacturer Identification Updates required Provide your company name, address, phone, fax, web address, FEIN, and name and title of person completing the form. The NPM shall update its certification list at least 30 days prior to any addition to or modification of the NPM’s brand families by executing and delivering a supplemental certification to the Attorney General. When is this Certification due? The annual Certification must be filed with the Attorney General no later than April 30 of each year. An initial certification may be filed at any time. Part 3: Brand Family Certification • • • Fabricator: Entity that assembles the tobacco product for consumer use, i.e., assembles tobacco into cigarettes or blends and packages tobacco into RYO tobacco. Brand Family: Provide the brand name, which could include many brand styles (menthol, 100's, etc.). Do not list each style in Part 3. Identify each Brand Family of all cigarettes that the company intends to sell in Illinois, either directly or indirectly through any distributor, retailer or similar intermediary, and seeks to have included in the Directory. American LegalNet, Inc. www.FormsWorkFlow.com • • • • • • • • • If more than one company manufactures a brand you are certifying (e.g., you manufacture only the RYO or only the menthol cigarettes, etc. for a given brand), provide a written explanation of which brand styles you manufacture. Identify the other manufacturer by name and address, and provide a list of brand styles they manufacture, if known. If the identity of the other manufacturer is unknown, provide the name and address of the trademark owner for the brand. Only one company can certify for a brand family. Indicate by asterisk (*) brands which are no longer sold/offered for sale in Illinois. Check whether the product is cigarettes or RYO. Where a brand is offered as both cigarettes and RYO, make a separate entry for each. Units sold: List the total RYO ounces and total cigarette sticks separately for both the preceding calendar year and the current calendar year (as of the date of certification). A Brands Addendum page is included with the certification packet and is available on the Attorney General’s website. Where addendum pages are used, the total of units sold should be entered on the final addendum page. If you were not the manufacturer of a listed brand in the preceding year, identify by name and address the manufacturers of such Brand Families. Provide original packaging for one brand style which is representative of each brand family to be certified. Flat, empty cartons are preferred. Place a check mark in the column provided for each brand family for which packaging is supplied. Submit new packaging each time you change your packaging or add new brand families. The Attorney General may require a tobacco product manufacturer to submit any additional information including, but not limited to, samples of the packaging or labeling of each brand family, as is necessary to enable the Attorney General to determine whether a tobacco product manufacturer is in compliance with the Escrow Enforcement Act of 2003 (30 ILCS 167/25(d)). Part 4: Certification of Escrow Account and Agreement • • • • • • • • Identify the name, address, phone and fax number for the financial institution (escrow agent) where the NPM has established a qualified Escrow Fund pursuant to the Tobacco Products Manufacturers’ Escrow Enforcement Act of 2003. Provide the name and e-mail address for a contact person at the financial institution. Escrow Account Number: Provide the account number for the main escrow account, if one exists. Illinois Sub-Account Number: Provide the account number for the Illinois sub-account to which a deposit or deposits have been made for the liability year identified in Part 5. Total amount held in this account for the State of Illinois: Amount held in the Illinois sub-account identified (in this part) as of the date of certification. If there are any other accounts held for the benefit of the State of Illinois, provide the total amounts held in these accounts (including the sub-account listed in Part 4) as of the date of certification. If your escrow agreement has been approved by the Attorney General under the Tobacco Products Manufacturers’ Escrow Enforcement Act of 2003 (eff. Jan. 1, 2004), check “Yes.” Please provide the effective date of the Escrow Agreement as well as the date of approval by the Attorney General and attach an executed copy. If your escrow agreement has not been approved by the Attorney General under the Tobacco Products Manufacturers’ Escrow Enforcement Act of 2003, check “No” and attach an executed copy. Part 5: Worksheet for Cigarettes Sold During Liability Year Use the instructions in the worksheet to convert RYO product to sticks and combine it with the cigarette stick count for the liability year. The result of this calculation will be used to determine the deposit amount in Part 6. Part 6: Deposit Amount • • • • • Use Lines 1 through 4 to calculate the total amount to be paid into escrow for the liability year identified in Part 5. The amount listed on Line 5 should include the total of any quarterly, reconciliation, or other payments which have been made for the liability year identified in Part 5, as of the date of certification. The amount listed on Line 6 is the difference, if any, between the amounts listed on Line 4 and Line 5. Attach proof of deposit(s) from your financial institution. Proof must include the account number of the Illinois sub-account, the date of deposit, and the amount of deposit. Such proof can be submitted as a letter from the bank. Provide an explanation for any discrepancy between the amounts listed on Lines 4 and 5. Part 7: Certification of Deposits, Withdrawals, and Transfers • • • • • • • • Use a separate page for each account or sub-account in which funds are held for the benefit of the State of Illinois. Identify the Illinois sub-account number and escrow agent (financial institution). Provide dates and amounts of deposits, withdrawals, and transfers for all activity prior to the date of certification. For ANY withdrawal or transfer, you must provide a brief explanation. For initial certification under the Tobacco Products Manufacturers’ Escrow Enforcement act of 2003, provide all deposit, withdrawal, or transfer activity (for each account) for the entire time each account has been funded. For any accounts where Illinois funds are NOT held separate and apart from that of other states, all activity must be reported, regardless of whether it involves funds held for the State of Illinois. An Accounts Addendum page is included with the certification packet and is available on the Attorney General’s website. Provide records from the Financial Institution to document any account activity. Part 8: Designated Contact Provide the name, title, address, phone and fax numbers, and e-mail address for the individual the Attorney General should contact with respect to matters relating to this certification. The designated contact is the individual who will receive Attorney General mailings, including the annual certification mailing. Part 9: Manufacturer Certification The authorized designee executing the certification must be an officer, principal, director or other authorized representative of the manufacturer. The authorized designee’s name and title must be legibly printed and the signature must be notarized. Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com