1 Maine 226 2019 Tobacco Product Manufacturer Annual Certificate of Compliance 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. Location of all Factories/Plants at which Products are fabricated: E. Telephone/E-mail: F. Name/Title of Person Completing Report: G. Name of any manufacturer with whom the applicant has an agreement or contract regarding fabrication of tobacco products: H. Does applicant actually physically fabricate all brand styles for which certification is sought? Yes No If not, which brand styles does applicant actually fabricate? I. Applicant is: A participating manufacturer under the Tobacco Master Settlement Agreement A non-participating manufacturer as defined in 22 M.R.S.A. 247 1580-H(9) J. Is Applicant a Tribal or Tribally Owned Entity? Yes No K. 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. Mail completed form to: Maine Attorney General 6 State House Station Augusta, ME 04333-0006 Attn: AAG , Tobacco Program American LegalNet, Inc. www.FormsWorkFlow.com 2 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 manufacturer222s 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 Marshal222s certification of reduced ignition propensity, in accordance with 22 M.R.S. 247 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 247904 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. BRAND and STYLE IDENTIFICATION Brands and styles for which certification is sought: (PLEASE INDICATE ANY CHANGES FROM 2017) Brand Style Attach sample packaging for each brand style that is new. IV. TRADEMARK HOLDER Brand Trademark Holder American LegalNet, Inc. www.FormsWorkFlow.com 3 V. 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) 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: B. Sales Information Brand Style Units sold in 2018 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. 247247 1580-G, et seq. and 22 M.R.S.A. 247 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 226 Financial Institution 1) Escrow Agent Information Name of Institution: Telephone Number: 2) Attach an executed copy of the current Escrow Agreement. American LegalNet, Inc. www.FormsWorkFlow.com 4 E. Escrow Deposit/Withdrawal History for Maine Are all quarterly or annual certificates of escrow compliance filed with the Attorney General222s Office true and accurate reflections of all sales and all escrow deposits made on behalf of Maine? Yes No. Attach amended certificates of escrow compliance. 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 applicant222s product in Maine. Failure to identify such a distributor may result in delay of certification or conditional certification. Distributor Distributor Address VI. 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: Subscribed and sworn to before me on this date: Signature of Notary Public: County of My Commission Expires: Mail the completed Certificate of Compliance to: Maine Office of Attorney General 6 State House Station Augusta, Maine 04333-0006 Attention: AAG, Tobacco Program American LegalNet, Inc. www.FormsWorkFlow.com