Commonwealth of Kentucky Certification of Tobacco Product Manufacturers (Revised January, 2009) GENERAL INFORMATION: Who is required to file this certification? Any tobacco product manufacturer that sells or intends to sell cigarettes or RYO within the Commonwealth of Kentucky, whether directly or through any distributor, retailer, or similar intermediary. No cigarettes may be stamped for sale and no RYO may be sold in Kentucky unless the manufacturer is on the directory of certified companies and the brands have been certified as fire safe under Kentucky law. Definitions: (a) “Brand Family” means all styles of Cigarettes sold under the same trade mark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, “menthol,” “lights,” “kings,” and “100s,” and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of Cigarettes. (b) “Cigarette” has the same meaning as in KRS 131.600. (c) “Directory” means the listing of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of Kentucky law and all Brand Families that are listed in such certifications. KRS 131.610. (d) “Master Settlement Agreement” has the same meaning as in KRS 131.600. (e) “Non-participating Manufacturer” means any Tobacco Product Manufacturer that is not a Participating Manufacturer. (f) “Participating Manufacturer” has the meaning given that term in Section II(jj) of the Master Settlement Agreement and all amendments thereto. (g) “Qualified Escrow Fund” has the same meaning as that term is defined in KRS 131.600. (h) “Stamping Agent”means a person, including a distributor, wherever residing or located, that is authorized to affix tax stamps to packages or other containers of Cigarettes under KRS 138.146 or any person that is required to pay the excise tax imposed pursuant to KRS 138.155 on Cigarettes. (i) “Tobacco Product Manufacturer” has the same meaning as that term is defined in KRS 131.600. (j) “Units Sold” has the same meaning as that term is defined in KRS 131.600. When is this certification due? The certificate of compliance must be filed and approved prior to sales of cigarettes or RYO in Kentucky. If a company is on the directory, an annual certification must be delivered to our office on or before April 30th. A directory of compliant manufacturers will be published by July 1 each year on the Kentucky Revenue Cabinet website (http://www.revenue.state.ky.us). American LegalNet, Inc. www.FormsWorkflow.com SPECIFIC INSTRUCTIONS: Part 1: Manufacturer's Identification. Identify the name, street and mailing address, telephone, fax number and electronic mail address. Please provide a list of officers and those owners with 10% equity or more. Part 2: Sales Year. Identify the sales year. Part 3: Brand Family Identification: Identify by Brand Family and Brand name all of the cigarettes or RYO that the Tobacco Product Manufacturer intends to sell in Kentucky, whether directly or through any distributor, retailer, or similar intermediary, and to be included in the Directory. Only the specific brands identified will be included in the Directory. Also provide a full-size color sample of each brand family’s pack and carton label and packaging (if not already provided), trademark documentation and current federal approval letters for all brands. Any cigarette Brands must be certified as fire safe with the Kentucky Fire Marshall to be listed as approved for sale in Kentucky. Proof of fire safe certification is required. A Participating Manufacturer shall include a list of its Brand Families. The Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General. A Non-Participating Manufacturer shall include in its certification (i) a list of all of its Brand Families and the number of Units Sold for each Brand Family that were sold in the State during the preceding calendar year, (ii) a list of all of its Brand Families that have been sold in the State at any time during the current calendar year, (iii) indicating, by an asterisk, any Brand Family sold in the State during the preceding calendar year that is no longer being sold in the State as of the date of such certification, and (iv) identifying by name and address any other manufacturer of such Brand Families in the preceding or current calendar year, (v) list Kentucky stampers sold to and amounts sold. (The Non-Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General). Part 4: Non-Participating Manufacturer Information A. Verify that the Non-Participating Manufacturer is registered to do business in Kentucky or has appointed an agent for service of process located in Kentucky and provided notice thereof. Proof of appointment acceptance must be on file with the Attorney General. Timely notice is required for any change in agent. (30 days prior to termination of agent; proof of new agent required 5 days before termination; 5 days after agent terminates). B. Identify (i) the name, address and telephone number of the financial institution where the NonParticipating Manufacturer has established a Qualified Escrow Fund pursuant to KRS 131.602 and (ii) the account number of such Qualified Escrow Fund and any sub-account number for Kentucky (escrow agreement must be included for approval if not previously submitted). C. Identify (i) the amount such Non-Participating Manufacturer placed in such fund for Cigarettes sold in the State during the preceding calendar year, the date and amount of each such deposit; and (ii) the amount and date of any withdrawal or transfer of funds the Non-Participating Manufacturer made at any time from such fund or from any other Qualified Escrow Fund. Part 5: Execution by Authorized Designees. The person executing the Certification must be an authorized representative of the Tobacco Product Manufacturer identified in Part 1. The Designee’s name and title must be printed and the Certification must be executed in the presence of an authorized notary. American LegalNet, Inc. www.FormsWorkflow.com Commonwealth of Kentucky-Tobacco Product Manufacturer Certification Part 1: Tobacco Product Manufacturer Identification Company: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ Phone: _________________________________________ Email: _________________________________________ FAX __________________________________ Name/Title of Person Completing Report: _______________________________________________________________ The Tobacco Product Manufacturer identified above is, as of the date of this Certification (Initial One): ________ A Participating Manufacturer under the Tobacco Master Settlement Agreement ________ A Non-Participating Tobacco Product Manufacturer in full compliance with KRS 131.602 Part 2: Sales Year Year of Sales for this Certificate of Compliance is: (Complete a separate certification for each year of sales) ______________ Part 3: Brand Family Identification (Attach additional Sheets if Necessary) Participating Manufacturers complete A & B; Non-Participating Manufacturers complete A through E. Samples of labels and packaging for each brand are required, as well as copies of manufacturing permits/licenses, trademark documentation, current federal approval letters and fire safe certification (unless already on file). (Note: Nine-hundredths of an ounce (.09) of RYO tobacco counts as 1 cigarette). A. Brand Family1 B. Brand Name C. Units Sold Preceding Yr D. Units Sold Current Yr E. Manufacturer (include full address information for each location) F. List KY licensed stampers and amounts sold by brand. (Use additional or separate sheets if necessary.) 1 Indicate with an asterisk (*) those brands that will not be sold in the current year. American LegalNet, Inc. www.FormsWorkflow.com Part 4: Non-Participating Manufacturer Information A. Registered Agent in Kentucky for service of process (provide proof of acceptance/ appointment) Agent Name: ____________________________________________________________________________________ Company: ____________________________________________________________________________________ Address: ____________________________________________________________________________________ Phone: _________________________________________ B. Qualified Escrow Fund – Financial Institution (provide copy of escrow agreement if not on file) FAX __________________________________ Name of Institution: ______________________________________________________________________________ Address: ______________________________________________________________________________ Representative Name: ________________________________________ Phone: ______________________________ Escrow Acct No:________________________________________ State Account No: _____________________ C. Escrow Deposit/Withdrawal History for Kentucky Date Part 5. Deposit Withdrawal2 Balance Execution by Authorized Designee (all manufacturers) Under penalty of perjury, I, as authorized agent of the manufacturer, state that the information contained in this Certification is true and accurate. Designee (Print Name): ________________________________________ Title: _______________________ Signature of Designee: Date: _______________________ ________________________________________ Subscribed and sworn to before me on this date: ___________________________________________________ Signature of Notary Public: _____________________________________ City or County of_____________________ My Commission expires: ________________________________________ Mail the completed certificate of compliance to: Office of Attorney General 700 Capitol Avenue, Suite 118 Frankfort, KY 40601 Attn: Michael Plumley, Assistant Attorney General 2 Withdrawals must comply with KRS 131.602. Verification of compliance must be provided. American LegalNet, Inc. www.FormsWorkflow.com