State of Illinois Non-Participating Manufacturer NPM-3 Certification of Additional Information p. 1 of 4 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  2010  Annual Other:  _____________  Supplemental Part 2: Manufacturer Identification Company Name Mailing Address City State Phone Zip Code Fax Country FEIN Part 3: NPM Status References to cigarettes (includes roll-your-own) are to the brand families certified on the NPM-1 form submitted by the manufacturer identified in Part 2.  Yes  No NPM is the fabricator of the brand families listed on the NPM-1 form and intends for the cigarettes to be sold in the U.S., including cigarettes intended to be sold in the U.S. through an importer.  Yes  No NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the U.S.  Yes  No NPM is a successor as defined in 30 ILCS 168/10. Part 4: Additional Information Requested by Attorney General’s Office Check One: ► All NPMs must provide the information requested in this section. ► Provide a response to each question or indicate N/A. ► Each attachment must indicate the question to which it corresponds. Response Provided Does Not Apply   1. A copy of your current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or as an importer as required by 26 U.S.C. §5712 and §5713. Foreign NPMs should provide importer permits for each company that will import its cigarettes into the U.S.   2. Name, address and phone number of the Trademark owner and any license agreement or other document providing permission to the NPM to use the trademark for each of the brand families certified in Part 3 of the NPM-1 certification form.   3.   4. A listing of all company officers and owners (all persons with an equity interest of 10% or more in company).   5. A complete list of cigarettes (including roll-your-own tobacco) that NPM, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and place of manufacture for those brands.   6. A copy of the current corporate documents, such as articles of incorporation, charter or certificate. A complete list of other tobacco products (e.g. cigars, pipe tobacco, smokeless tobacco, etc.) that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands. American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Non-Participating Manufacturer NPM-3 Certification of Additional Information p. 2 of 4 Part 4 (continued) : Additional Information Requested by Attorney General’s Office Check One: ►All NPMs must provide the information requested in this section. ► Provide a response to each question or indicate N/A. ► Each attachment must indicate the question to which it corresponds. Response Provided Does Not Apply   7. A complete list of Little Cigars that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands.   8. A list of prior manufacturers of each of the brand families certified in Part 3 of the NPM-1 certification form. 9. For each brand family certified in Part 3 of the NPM-1 certification form, provide the following:   a. location of manufacture applies to each brand family  yes  no (explain)     b. name, address and phone number of the factory manager(s) Brand Family c. the date manufacturing d. the price you intend to sell each brand first commenced family to distributors licensed in Illinois American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Non-Participating Manufacturer NPM-3 Certification of Additional Information p. 3 of 4 Part 4 (continued) : Additional Information Requested by Attorney General’s Office Check One: ►All NPMs must provide the information requested in this section. ► Provide a response to each question or indicate N/A. ► Each attachment must indicate the question to which it corresponds. Response Provided Does Not Apply   e. identification of intended distributors   f.   g. the name, address and contact for the fabricator, if other than the NPM, and a copy of any agreement or contract between the fabricator and NPM regarding the manufacture and/or sale of cigarettes   10. If NPM or any of its principals previously imported or distributed cigarettes or roll-your-own tobacco in the U.S., list each brand family name and the manufacturer name and address for each brand family.   11. If NPM delivers cigarettes directly to a distributor located in and licensed to stamp for Illinois, list all distributors located in and licensed to stamp for Illinois to whom cigarettes were delivered and attach copies of the RC 36 CM reports filed with the Illinois Dept. of Revenue for deliveries during the liability sales year. If NPM does not sell directly to Illinois licensed distributors, provide a list of all importers and/or distributors to which cigarettes or roll-your-own tobacco were sold during the liability sales year.   12. For each brand family of roll-your-own tobacco being certified, state whether NPM pays the Illinois OTP tax and provide a complete list of retailers to whom the roll-your-own tobacco is intended to be sold in Illinois. If NPM pays the Illinois OTP tax, attach a copy of the State of Illinois distributor license.   13. If NPM intends to sell or authorizes any other entity to sell any cigarettes or roll-your-own by mail order or through the internet, provide the internet website and/or identify publications. Attach copies of all reports, if any, filed with the Illinois Dept. of Revenue to comply with the Jenkins Act (Chapter 10A of Title 15 of the U.S. Code, Section 375 et seq.) for sales in the last 12 months. Attach copies of any agreements authorizing another to sell your brand families by mail order or through the internet. If NPM has a policy or protocol regarding the prevention of sales of your products via the internet, please provide a copy.   14. For each brand family (cigarettes only) certified in Part 3 of the NPM-1 certification form, provide the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act (15 U.S.C. §1335a) and attach copies of all certificates of compliance.   15. For each brand family (cigarettes only) certified in Part 3 of the NPM-1 certification form, provide a copy of the current FTC rotation plan approval letter and the name and address of the entity that filed the health warning rotation plan with the FTC.   16. If the escrow agreement submitted by NPM is encumbered by granting a security interest in the escrow fund to a third party, provide UCC filings and Security Agreement pertaining to this security interest in the escrow fund.   17. Provide a list of states that have certified NPM and the brand families certified. If any state has refused to list or removed NPM from a state’s directory, identify the state(s). explanation of manufacturing process and the precise activities that constitute fabrication of the cigarettes or roll-your-own tobacco American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Non-Participating Manufacturer Certification of Additional Information NPM-3 p. 4 of 4 Part 4 (continued): Additional Information Requested by Attorney General’s Office     19. Provide a notarized statement that the brand styles you are attempting to certify are not banned effective September 22, 2009 by the FDA legislation that bans additives, including artificial or natural flavors, that are characterizing flavors of tobacco product other than tobacco or menthol. See Section 907(a)(1)(A) of the Federal Food, Drug and Cosmetic Act (FFDC) as amended by the Family Smoking Prevention and Tobacco Control Act (FSPTC).   20. Provide documentation that all required payments have been made for all cigarette brands for 2010 pursuant to the Tobacco Transition Payment Program as required by Federal law under The Fair and Equitable Tobacco Reform Act of 2004 (P.L. 108-357).   21. Provide Packaging for each brand family certified in Part 3 of the NPM-1 certification form as part of the Annual Certification for LY 2010 that contains similar descriptors to light, mild, or low or provide FDA authorization for such descriptors or confirm that no packaging contains such descriptors. See Section 911(b)(2)(ii) and 911(b)(3) of the Federal Food Drug and Cosmetic Act as amended by the Family Smoking Prevention and Tobacco Control Act (21 USC 387k). 18. For each brand family certified in Part 3, provide proof of the submittal to FDA of the disclosure of tobacco product ingredients that was due by June, 2010 as required by §904 of the Federal Food, Drug and Cosmetic Act (FFDC) as amended by the Family Smoking Prevention and Tobacco Control Act (21 USC 387d). Please note that importers or their agents must submit the information to FDA for foreign tobacco product manufacturers. Part 5: 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 Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com