State of Illinois NPM-S Non-Participating Manufacturer’s Sales Information Manufacturer Identification Company Name Date Mailing Address City State Zip Code Phone Country Fax Name and title of person completing this form Mail-to Address (if different from above) Name Mailing Address City State Zip Code Phone Fax Country E-Mail Liability Year 2010 Manufacturer’s Records Other: (Attach Addendum pages as necessary) Instructions for the Manufacturer: List each distributor which sells your product(s) in the State of Illinois. For each distributor, provide the sales volume according to your records for each brand family for the liability year and provide copies of invoices or other documents that support the sales volume listed. In addition, provide the name, address and contact person for all distributor s to whom you sold product for the liability year. You must retain all invoices and documentation of sales and other information relied upon for a period of 5 years, unless otherwise required by law to maintain them for a greater period of time. By completion of this form, the Manufacturer identified above requests that the Attorney General: • • • identify distributors, in addition to those the manufacturer has listed below, which have reported the sale of manufacturer’s brands in Illinois during the liability year compare the brand sales volume below to that which distributors have reported to the Attorney General determine whether an escrow payment based on the manufacturer’s reported sales volume represents adequate funding for the liability year Sales Volume Distributor Brand Family Distributors Reported Check One Manufacturer’s Records as of: (AG Use Only) ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO Total of RYO Ounces Total of Cigarette Sticks Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com NPM-S State of Illinois Sales Addendum Non-Participating Manufacturer’s Sales Information Manufacturer Identification Company Name Sales Addendum Page ____ of ____ Sales Volume Distributor Brand Family Check One Distributors Reported Manufacturer’s Records as of: (AG Use Only) ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO ☐ Cigarette ☐ RYO Total of RYO Ounces Total of Cigarette Sticks Rev. 3/7/2011 American LegalNet, Inc. www.FormsWorkFlow.com