OFFICE OF THE KANSAS ATTORNEY GENERAL NON-PARTICIPATING MANUFACTURER CERTIFICATION OF ESCROW COMPLIANCE FORM R EVISED J ANUARY 28, 2011 Non-Participating Manufacturers whose products are reported as sold in Kansas will receive written notice from the Attorney General following each quarter advising of its escrow obligation due. Please complete and return this form after receiving your official notice. ESCROW QUARTER This Certification of Escrow Compliance Form is an (Check appropriate box below.) Initial Submission Amendment to Previous Submission For sales reported during year ____________ (Check appropriate box below.) 1st Quarter (January 1 – March 31) 3rd Quarter (July 1 – September 30) 2nd Quarter (April 1 – June 30) 4th Quarter (October 1 – December 31) MANUFACTURER INFORMATION Manufacturer: ____________________________________________________________ Mailing Address: ____________________________________________________________ Street Address: ____________________________________________________________ The street address is the physical location of the manufacturing plant. Phone Number: ________________________ Fax Number: ______________________ E-Mail Address: ____________________________________________________________ Website: ____________________________________________________________ NPM Certification of Escrow Compliance Form Revised January 28, 2011 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ESCROW ACCOUNT INFORMATION Financial Institution: ____________________________________________________________ Contact Name/Title: ____________________________________________________________ Mailing Address: ____________________________________________________________ ____________________________________________________________ Phone Number: ________________________ Fax Number: ______________________ E-Mail Address: ____________________________________________________________ Account Number: ____________________________________________________________ Kansas Sub-Account Number: ____________________________________________________________ ESCROW OBLIGATION Calculate the escrow obligation owed for the escrow quarter using the following rates, already adjusted for inflation pursuant to K.S.A. 50-6a02(a). Please refer to your official notice to correctly complete this portion. If completing the form electronically, mathematical functions will automatically calculate. Sales Year 2004 2005 2006 2007 Rate Per Unit $ 0.0201300 $ 0.0208176 $ 0.0214421 $ 0.0251069 Sales Year 2008 2009 2010 2011 Rate Per Unit $ 0.0258601 $ 0.0266359 $ 0.0274350 $ 0.0282581 1. Enter cigarette units reported to Kansas in quarter: __________________ 2. Enter RYO ounces reported to Kansas in quarter: __________________ 3. Enter RYO units reported to Kansas in quarter: (Divide line 2 by .09.) __________________ 4. Enter total units reported to Kansas in quarter: (Add line 1 to line 3.) __________________ 5. Enter applicable rate per unit for sales year: (See chart above.) __________________ 6. Enter escrow obligation due: (Multiply line 4 by line 5.) __________________ NPM Certification of Escrow Compliance Form Revised January 28, 2011 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ESCROW DEPOSIT 7. Enter credit amount carried forward (if any): (Refer to your official notice.) __________________ 8. Enter amount deposited for this quarter: (Do not include credit from line 7.) __________________ 9. Enter credit amount remaining after satisfaction of escrow obligation (if any): (Add line 7 to line 8 and subtract line 6 from sum.) __________________ PROOF OF DEPOSIT Attach a letter from the financial institution holding your company’s qualified escrow fund verifying the deposit of the amount owed for this quarter, including the date such deposit was made. Failure to provide this attachment will result in an incomplete certification. (Check appropriate box below.) Attached Not Applicable VERIFICATION OF CERTIFICATION I certify that, to the best of my knowledge, all of the information contained in this certification and any attachments are true and accurate, and that I am authorized, under the laws of the State of Kansas or the jurisdiction where the manufacturer resides or is organized, to bind the manufacturer making this certification. I certify that, for any brand family acquired from a previous manufacturer, all previous escrow payments required by K.S.A. 50-6a03 have been paid in full. I certify that I understand the Kansas Attorney General may require additional information to determine if the manufacturer has made the required escrow payments. I certify under penalty of perjury under the laws of the State of Kansas that the foregoing is true and correct. Executed this _______ day of __________________, 20______. SUBMISSION OF CERTIFICATION OF ESCROW COMPLIANCE FORM ____________________________________ Signature of Authorized Officer or Agent Mail this completed form and all attachments to: ____________________________________ Name (Please Print) Office of the Kansas Attorney General Attn: Tobacco Enforcement Unit 120 S.W. 10th Ave., 2nd Floor Topeka, KS 66612-1597 ____________________________________ Title (Please Print) NPM Certification of Escrow Compliance Form Revised January 28, 2011 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com OPTIONAL REQUEST FOR STAMPING AGENT NAMES Pursuant to K.S.A. 50-6a11(c), I hereby request the Kansas Attorney General to provide my company with the name of any stamping agent who reported selling my company’s tobacco products this quarter. I understand the Kansas Attorney General is not obligated to provide such information but may do so upon the approval of this escrow compliance form, including the satisfaction of any escrow obligation due. ____________________________________ Signature ________________________ Date NPM Certification of Escrow Compliance Form Revised January 28, 2011 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com