Failure to fill out this form completely may result in delay or denial of certification Company Name Physical Address Mailing Address (if different) Website (if any) Physical Address of all Factories/Plants at which Products are Fabricated Telephone Number Fax Number E - mail Address Name/Title of Person Completing Report Name of any manufacturer with whom the applicant has an agreement or contract regarding fabrication of tobacco products A. This Quarterly Certification and Filing Deadlines are for t he following period (check one): January 1 March 31, 201 9 Original Amended Deposit to Maine sub - a ccount deadline: April 30, 201 9 amount deposited $ date . April 1 June 30, 201 9 Original Amended Deposit to Maine sub - account deadline: July 30, 201 9 amount deposited $ date . July 1 September 30, 2019 Original Amended Deposit to Maine s ub - account deadline: October 31 , 201 9 amount deposited $ date . October 1 December 31, 2019 Original Amended Deposit to Maine sub - acc ount deadline: January 30, 20 20 amount deposited $ date . 2 01 9 - Maine Non - Participating Manufac turer Quarterly Certificate of Escrow Compliance PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION American LegalNet, Inc. www.FormsWorkFlow.com 2 PART 2: BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) The non - participating manufacturer identified in Part 1 has the following brand families /styles , each of which the manufacturer affirms are to be deemed its cigarettes and/or RYO for purposes of 22 M.R.S.A. 247247 1580 - G, et seq . Brand Family Brand Style Answer all of the following questions: A. annual c ertification continues to be the registered agent for this TPM. Yes No B. recent annual certification remains accurate. Yes No C. The escrow agreement annual certification remains in force and unchanged. Yes No D. If the answer to A, B and/or C above is No , explain and provide supporting d ocumentation. E. Stamping Agents/Distributors Distributor Distributor Address Brand PART 3: AGENT/DISTRIBUTOR INFORMATION PART 2: BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) American LegalNet, Inc. www.FormsWorkFlow.com 3 Under penalty of perjury, I state that the information contained in this Certification , including but not limited to any accompanying statements or attachments, is true and accurate , and that I am a person authorized to bind the tobacco product manufacturer making this Certification under both the laws of the State of Maine and of the jurisdictions where the tobacco product manufacturer is organized and where the tobacco product manufacturer conducts business . sign Mail the completed certificate of compliance to: Maine Office of Attorney General 6 State House Station Augusta, Maine 04333-0006 Attention: AAG PART 4: EXECUTION BY AUTHORIZED DESIGNEE Designee (Print Name) Title Signature of Designee Date Subscribed and sworn to before me on this date: Signature of Notary Public: County of My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com