2010 Kentucky Annual Certificate of Nonparticipating Tobacco Product Manufacturer Compliance Part 1: Manufacturer’s Identification 1. 2. 3. 4. 5. Name: _______________________________________________________________________________________ Street address: _________________________________________________________________________________ City, state, country, ZIP: _________________________________________________________________________ Telephone number: _____________________________________________________________________ Electronic mail address: _________________________________________________________________ Part 2: Liability Year (Sales year) The liability year for this certificate is: 2010 _____________________________________________________________________________________ Part 3: Units Sold 6. 7. Number of individual cigarettes and RYO sold by the manufacturer identified above during the liability quarter subject to Kentucky excise tax as follows (by brand; nine hundredths (.09) of an ounce of RYO tobacco counts as 1 stick): 1)_____________________________2)____________________________ 3)_____________________________ 4) ____________________________ 5) ____________________________ 6) ____________________________ Total sticks: 7) _______________________________ Part 4: Deposit Amount For the liability year 2007 and after, the base rate per cigarette is ...... 0.0188482 8. The appropriate rate for the liability year as adjusted for inflation* is: 8. $0.0274350 9. Multiply Line 8 by total of Part 3, Line 7, and write the amount here (Total Escrow Deposit due for the quarter): 9. ___________________ Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the institution if you have not previously provided one or if it has been amended. Part 5: Financial institution 10. Name: _______________________________________________________________________________________ 11. Street address: ________________________________________________________________________________ 12. City, state, country, ZIP:_________________________________________________________________________ 13. Escrow account number _____________________________________ 14. Total amount held in this account after current deposit: $_________________________________ 15. Escrow agent: ________________________________________ 16. Phone Number: _______________________________ Part 6: Authorized Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. Sworn to and subscribed before me this ____ day of _________________, 20___ _________________________________________________ Signature of Notary Public _______________________________________________ Print the name of authorized agent Title _______________________________________________ Signature of authorized agent Date City / State: _______________________________________ My commission expires ________/__________/__________ * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. This form is due April 30, 2011 and may be sent to: Kentucky Office of Attorney General, 700 Capitol Avenue, Suite 118, Frankfort, KY 40601, (Attention: Michael Plumley, Assistant Attorney General). American LegalNet, Inc. www.FormsWorkFlow.com