STATE OF LOUISIANA NON-PARTICIPATING MANUFACTURER CERTIFICATION PURSUANT TO LSA-R.S. 13:5071 et seq. Part 1: Tobacco Product Manufacturer Identification Company: _____________________________________________________________________ Physical Address: _________________________________________________________________ Address: _____________________________________________________________________ Phone: ______________________________ FAX: ________________________________ Alternate Address: ________________________________________________________________ Address: _____________________________________________________________________ Phone: ______________________________ FAX: ________________________________ Name of Person Completing Report: __________________________________________________ Title: _______________________________ E-mail: _______________________________ Part 2: Sales Year By Quarter Year of Sales for this Certificate of Compliance is: __________________ (Complete a separate certification for each year of sales) Part 3: Louisiana Agent for Service of Process (For Companies that have not registered to do business in this State with the Louisiana Secretary of State) Agent Name: _____________________________________________________________________ Company: _____________________________________________________________________ Address: _____________________________________________________________________ Address: _____________________________________________________________________ Phone: ______________________________ E-mail: _____________________________________________________________________ FAX: ________________________________ Attach proof that this Louisiana Agent has been appointed and continually engaged in this state to act as agent for service of process on whom all process and any action or proceeding against the Tobacco Product Manufacturer concerning or arising out of the enforcement of LSA R.S. 13:5071 et seq. and LSA R.S. 13:5061 et seq., may be served in any manner authorized by law. Date: ________ Initial: ________ 1 American LegalNet, Inc. www.FormsWorkflow.com Part 4: Qualified Escrow Fund – Financial Institution Name of Institution: _________________________________________________________________ Address: ______________________________________________________________________ Representative Name: ______________________ Phone: Escrow Acct. No.: ______________________________ ________________________ Date established: _______________________ State Sub-Account No.: _____________________ Date established: _______________________ Attach proof from the Financial Institution of the account balance(s) provided herein, and instruct the Financial Institution to mail monthly statements to this office reflecting the current account balance(s). Has the Escrow Agreement been presented to the Attorney General (date)? ___________________ Date executed?: ________________________________ Amended?: ________________________ (Include all amendments applicable to La.) Escrow Deposit/Withdrawal History for Louisiana Date Part 5: Deposit Withdrawal Balance Non-Participating Manufacturer Certifications: A. That, as of the date of this certification, the certifying Tobacco Product Manufacturer herein, certifies that it is in full compliance with LSA R.S. 13:5061 et seq. and 13:5071 et seq., including all installment payments required by LSA R.S. 13:5075(E); B. That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges the requirement to hereafter, unless otherwise directed by the Attorney General, make quarterly escrow deposits in order to comply with LSA R.S. 13:5061 et seq.; C. That, no later than the thirtieth day of April of each of the following years, the certifying Tobacco Product Manufacturer herein, will execute and deliver to the Louisiana Attorney General’s Office, a current certification in this same form or another as prescribed by the Louisiana Attorney General’s Office. Date: ________ Initial: ________ 2 American LegalNet, Inc. www.FormsWorkflow.com D. That, as of the date of this certification, the certifying Tobacco Product Manufacturer herein, certifies that the Brand Family/Families listed herein and as attachments, and all supporting information, is true, correct, and complete; E. That, the certifying Tobacco Product Manufacturer herein hereby affirms that the Brand Family/Families listed herein are deemed to be its cigarettes and/or roll-your-own for purposes of LSA R.S. 13:5061 et seq. and 13:5071 et seq. and that as the certifying manufacturer herein, attests that he/she has read and understands the obligations, responsibilities and laws applicable to all Tobacco Product Manufacturers and NonParticipating Manufacturers pursuant to aforementioned Louisiana laws; F. That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges that the Brand Family/Families will not be authorized for sale in Louisiana if the “country of origin” on the packaging differs from the “country of origin” listed on the Attorney General’s brand directory; G. That, the certifying Tobacco Product Manufacturer herein, certifies that thirty days prior to the addition to or modification of the Brand Family/Families listed in Attachment #1 and #2, it will execute and deliver a supplemental certification to the Louisiana Attorney General’s Office; H. That, the certifying Tobacco Product Manufacturer herein, certifies that thirty days prior to the termination of the authority of its Louisiana agent, for service of process, it will provide notice to the Attorney General and Secretary of the Department of Revenue, and five days prior to the termination of authority of an agent, for service of process, will provide proof to the satisfaction of the Attorney General of the appointment of a new Louisiana agent, for service of process; I. That, the certifying Tobacco Product Manufacturer herein, will maintain all invoices and documentation of sales, imports and exports as well as other such information relied upon for such certification for a period of five years, unless otherwise required by law to maintain them for a greater period of time; J. That, the certifying Tobacco Product Manufacturer herein, hereby acknowledges the requirement to hereafter, unless otherwise directed by the Attorney General, to submit and agree to the jurisdiction of the 19th Judicial District of the Parish of East Baton Rouge over all Non-Participating issues, as detailed in LSA 13:5061 et seq. and 13:5071 et seq. Date: ________ Initial: ________ 3 American LegalNet, Inc. www.FormsWorkflow.com Under penalty of perjury, I state that the information contained in this Certification (including Attachment #1 and #2) is true and accurate. Further, I understand that any misinformation, fabrication, inaccuracies, and/or material omissions, or any actions in violation of Louisiana law or the statements hereby attested to, may lead to the removal or affect the status of an approved Tobacco Product Manufacturer and their brand or brands. Signature of Authorized Agent: __________________________Title: _________________________ Name of Authorized Agent: ____________________________Date: __________________________ Signature of Notary Public: __________________________ Parish or County of ________________ Sworn and Subscribed before me on this date: _____________________ My Commission Expires: _______________________________________ Mail this completed certificate of compliance to: STATE OF LOUISIANA OFFICE OF THE ATTORNEY GENERAL TOBACCO SETTLEMENT ENFORCEMENT UNIT P. O. BOX 94005 1885 North Third Street, Fourth Floor BATON ROUGE, LA 70804-9005 AFFIX NOTARY SEAL HERE Date: ________ Initial: ________ 4 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT #1 – BRAND FAMILIES TO BE CERTIFIED IN LOUISIANA List all Brand Families presented for Certification in Louisiana (LA). Note: Only brand families listed here will appear on the Attorney General’s brand directory. (Attach Additional Sheets if Necessary). Brand Families1 to be sold in LA Trademark Holder Units Sold in LA (List quantity and year sold) Country of Origin (as it appears on the packaging) Name of Manufacturer and Manufacturing Facility Location (complete physical address) 1 “Brand Family” shall have the same meaning as defined in LSA R.S. 13:5072(1). NOTE 1: It is not necessary to list every brand in a brand family UNLESS the brands are manufactured at different locations and/or have a different country of origin printed on the packaging. NOTE 2: If the “country of origin” on the packaging does not match the “country of origin” on the brand directory, the product cannot be sold in LA. 5 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT #2 – ALL OTHER BRAND FAMILIES List all current and past brand families manufactured in the last Five (5) years. Note: Identify whether or not the brand family has been sold in Louisiana (LA) in the last Five (5) years. (Attach Additional Sheets if Necessary). Current and Past Brand Families2 Trademark Holder Units Sold in LA? (List quantity and year sold) Country of Origin Name of Manufacturer and Manufacturing Facility Location (complete physical address) 2 “Brand Family” shall have the same meaning as defined in LSA R.S. 13:5072(1). Please note that Roll-Your-Own (“RYO”) brands should be listed separately than cigarette brands, as they are also listed separately on the Louisiana Approved Tobacco Brand Directory. 6 American LegalNet, Inc. www.FormsWorkflow.com