09/3/03 Commonwealth of Kentucky Certification of Tobacco Product Manufacturers (Revised February, 20 1 8 ) 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 manufacture r is on the d irectory of certified companies and the brands have been certified as fire safe under Kentucky law. When is this certification due? If a company is on the directory, an annual certification must be delivered to our office on or before April 30 th . A revised directory of compliant manufacturers will be published by July 1 each year on the Kentucky Revenue Cabinet website ( https://revenue.ky.gov/Business/Tobacco - Tax/Pages/default.aspx ). Definitions: (a) es sold under the same trade mark and differentiated from one another by means of additional modifiers or descriptors, 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, a previously known brand of Cigarettes. (b) (c) 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) (e) - not a Participating Manufacturer. (f) the Master Settlement Agreement and all amendments thereto. American LegalNet, Inc. www.FormsWorkFlow.com 09/3/03 (g) (h) means a person, including a distributor, wherever residing or located, that is auth orized 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) he same meaning as that term is defined in KRS 131.600. (j) SPECIFIC INSTRUCTIONS : Part 1 : Manufacturer's Identification . Identify the name, street and mailing address, telephone, fax number and electr onic mail address. Please provide a list of officers , directors and owne rs 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 RY O 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 Direc tory. Also provide a full - size color sample of each brand s pack and carton label and packaging (if not already provided) , trademark documentation and current federal approval letters for all brands. NOTE: Any cigarette Brands must be certified as fire safe with the Kentucky Fire Marshall to be listed as approved for sa le in Kentucky. PACT act registration is also required. A Pa rticipating Manufacturer shall include a list of its Brand Families. The Participating Manufacturer shall update such list thirty calendar days prior to any modification of its Brand Families b y 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 sol d 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 prece ding 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 American LegalNet, Inc. www.FormsWorkFlow.com 09/3/03 sold to . Also, list the UPC code for each brand style. ( The Non - Participating Manufacturer shall update such list thirty calendar days prior to any 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. Proo f 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). B. Identify (i) the name, address and telephone number of the financial institution where the Non - Participating 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 (e scrow agreement must be included for approva l if not previously submitted or if modified ). 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 a mount 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. D. Provide information for financial instrument curre ntly in place as required by KRS 131. The amount must be the higher of $50,000 or the highest quarterly escrow deposit in the last 12 months. E. Provide information on delisting from tobacco directories of other states in the past year . F. Provide informatio n on any criminal convictions or guilty pleas within ten years of the end date of parole or sentence against the company, officers or employees. G. Provide list of all importers into the United States if product is imported and certify that each importer ag rees to be jointly and severally liable for any escrow default due to Kentucky. Part 5 : Execution by Authorized Designees . The person executing the Certification must be an authorized representative of the Tobacco Product Manufacturer identified in Part executed in the presence of an authorized notary. American LegalNet, Inc. www.FormsWorkFlow.com 09/3/03 Commonwealth of Kentucky - Annual Tobacco Product Manufacturer Certification Part 1: Tobacco Product Manufacturer Id entification Company: Address: Phone: F AX Email: Names of Officers, Directors and Owners: Name/Title of Person Completing Certification : 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 Ce rtificate of Compliance is: Part 3: Brand Family Identification (Attach additional Sheets if Necessary) Participating Manufacturers complete A & B; Non - Participating Manufacturers complete A through G . Samples of labels and packagi ng for each brand are required, as well as copies of manufacturing permits/ licenses, trademark documentation, agreements, current federal approval letters , fire safe certification and PACT act registration , unless already on file. ( Note : Nine - hundredths of an ou nce (.09) of RYO tobacco counts as 1 cigarette). A. Brand Family 1 B. Brand Name C. Units Sold Preceding Yr D. Units Sold Current Yr E. Manufacturer (include full address information for each location) F. List of KY - licensed sta mpers sold to. G. UPC Cod e s (please include spreadsheet or disc with case, carton and pack UPC) 1 Indicate with an asterisk (* ) those brands that will not be sold in the current year. American LegalNet, Inc. www.FormsWorkFlow.com 09/3/03 Part 4: Non - Participating Manufacturer Information A. Registered Agent in Kentucky for service of process ( provide proof of acceptance/ appoi ntment) Agent Name: Company: Address: Phone: Email : B. Qualified Escrow Fund Financial Institutio