Maine – 2011 Tobacco Product Manufacturer Annual Certificate of Compliance Mail completed form to:       Maine Attorney General       6 State House Station       Augusta, ME  04353       Attn:  Vivian Mikhail, AAG  Failure to complete this form complete and provide all requested documentation may result in delay or denial of certification I. MANUFACTURER INFORMATION A. Company Name: B. Physical Address: C. Mailing Address (if different): D. Website (if any): E. Physical Address of all Factories/Plants at which Products are Fabricated, identified by product: ____________________________________________________________________________ ____________________________________________________________________________ F. Telephone Number: _________________________________________________________ G. E-mail Address: ___________________________________________________________ H. Name/Title of Person Completing Report: _______________________________________ ____________________________________________________________________________ I. Name of any manufacturer with whom the applicant has an agreement or contract regarding fabrication of tobacco products: ___________________________________________________________________________ J. Does applicant actually physically fabricate all brand styles for which certification is sought? Yes No If not, which brand styles does applicant actually fabricate? _________________________ K. Applicant is: A participating manufacturer under the Tobacco Master Settlement Agreement A non-participating manufacturer as defined in 22 M.R.S.A. § 1580-H(9) L. If Applicant is a Participating Manufacturer, indicate the date when Applicant joined the MSA as an OPM or SPM: M. If Applicant joined the MSA by an amendment, please state the Amendment #: 1    American LegalNet, Inc. www.FormsWorkFlow.com N. Is Applicant a Tribal or Tribally Owned Entity? Yes No O. If located in the U.S., Applicant Manufacturer’s Federal Taxpayer ID: Contract Manufacturer(s)’s Federal Taxpayer ID: II. DOCUMENTS REQUIRED FOR ALL BRAND STYLES FOR WHICH CERTIFICATION IS SOUGHT A. A copy of the current U.S. Federal Trade Commission approval of cigarette health warning rotation plans; B. A copy of the current U.S. Centers for Disease Control current approval of cigarette ingredients; C. A copy of the U.S. Patent and Trademark Office trademark registration or documentation establishing the manufacturer’s right to use those marks; D. A copy of any agreements or contracts with other manufacturers regarding fabrication of tobacco products; E. A copy of the Maine State Fire Marshal’s certification of reduced ignition propensity, in accordance with 22 M.R.S. § 1555-E; F. A copy of relevant U.S. Department of the Treasury Alcohol and Tobacco Tax and Trade Bureau permits; G. Proof of the submittal to U.S. Food and Drug Administration of the disclosure of tobacco product ingredients that was due by December 19, 2009 as required by §904 of the Federal Food, Drug and Cosmetic Act (FFDC) as amended by the Family Smoking Prevention and Control Act (21 USC 387d). Please note that importers or their agents must submit the information to FDA for foreign tobacco product manufacturers; and H. A notarized statement that the brand styles you are attempting to certify are not banned effective September 22, 2009 by the U.S. Food and Drug Administration legislation that bans additives, including artificial or natural flavors, that are characterizing flavors of tobacco product other than tobacco or menthol. See Section 907(a)(1)(A) of the Federal Food, Drug and Cosmetic Act (FFDC) as amended by the Family Smoking Prevention and Tobacco Control Act (FSPTC). III. JUDGMENT HISTORY Has the applicant ever had a complaint filed against it or had any judgment entered against it in any State concerning MSA obligations or non-compliance with escrow statutes? Yes No If yes, provide a copy of the judgment or complaint. 2    American LegalNet, Inc. www.FormsWorkFlow.com IV. BRAND and STYLE IDENTIFICATION A. Brands and styles for which certification is sought: Brand Style B. Attach sample packaging for each brand style: 1) That is new; 2) For which packaging has changed since previous certification; 3) That was not certified in Maine in the immediately preceding year. Please note: Applicants are under an on-going obligation to supplement this application with sample packaging when any material change is made to approved brand style packaging. V. TRADEMARK HOLDER Brand Trademark Holder VI. FOR NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURERS ONLY A. Is the applicant (check one): 1) The fabricator of the listed brands in this Certification which are intended to be sold in the United States including cigarettes intended to be sold in the United States through an importer. ATTACH A COPY OF ALL CONTRACT MANUFACTURING AGREEMENTS PERTAINING TO ANY PRODUCTS FOR WHICH CERTIFICATION IS SOUGHT. 2) The first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. If this option is checked, identify the following: a) cigarette fabricator: __________________________________ b) mailing address: _____________________________________ c) contact person: ______________________________________ d) telephone and facsimile numbers: _______________________ e) relationship to the applicant: ___________________________ YOU MUST ATTACH A COPY OF ANY AGREEMENT OR CONTRACT BETWEEN THE APPLICANT AND FABRICATOR FOR YOUR APPLICATION TO BE COMPLETE 3) Other. Please explain: _______________________________________________ 3    American LegalNet, Inc. www.FormsWorkFlow.com B. Sales Information Brand Style Units sold in 2010 Units sold in 2011 as of date of this application C. Registered Agent for Service of Process 1) The non-participating manufacturer has appointed and continues to engage the following agent located in Maine for service of process on whom all process, and any action or proceeding against it concerning or arising out of the enforcement of 22 M.R.S.A. §§ 1580-G, et seq. and 22 M.R.S.A. § 1580-L may be served in any manner authorized by law: Agent Name: _____________________________________________ Company: _______________________________________________ Address: ________________________________________________ Telephone Number: _______________________________________ 2) Please attach proof of the appointment and availability of the Agent. D. Qualified Escrow Fund – Financial Institution 1) Escrow Agent Information Name of Institution: _____________________________________________ Address: ______________________________________________________ Representative Name: ___________________________________________ Telephone Number: _____________________________________________ 2) Escrow Agreement Approval Has the Escrow Agreement been approved by the Attorney General? Yes No By Whom: ___________________________Approval Date: ________________________ 3) Please attach an executed copy of the Non-Participating Manufacturer’s current Escrow Agreement. E. Escrow Deposit/Withdrawal History for Maine (attach additional sheets if necessary) Are all quarterly or annual certificates of escrow compliance filed with the Attorney General’s Office true and accurate reflections of all sales and all escrow deposits made on behalf of Maine? Yes No. If not, please supply amended certificates of escrow compliance with this application. 4    American LegalNet, Inc. www.FormsWorkFlow.com Date Deposit Withdrawal Year of Sales F. Stamping Agents/Distributors You must have a Maine licensed distributor to sell in Maine. Complete this section for each stamping agent/distributor selling applicant’s product in Maine. Failure to identify such a distributor may result in delay of certification or conditional certification. Distributor Distributor Address VII. SIGNATURE AND DATE 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. Full Name: Title: Signature: Date: Mail the completed Certificate of Compliance to: Maine Office of Attorney General 6 State House Station Augusta, Maine 04333-0006 Attention: Vivian Mikhail, AAG 5    American LegalNet, Inc. www.FormsWorkFlow.com