Maine - 2008 Tobacco Product Manufacturer Certificate of Compliance [Failure to fill out this form completely may result in delay or denial of certification] PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION 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 The tobacco product manufacturer identified above, as of the date of this Certification, is (check one): A participating manufacturer under the Tobacco Master Settlement Agreement. A non-participating manufacturer as defined in 22 M.R.S.A. § 1580-H(9), and in full compliance with 22 M.R.S.A. § 1580-G, et seq. If the applicant certified it is a Non-Participating Tobacco Product Manufacturer, the named applicant is the Tobacco Product Manufacturer because (check one) it is 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. it is a successor of any entity described in 22 M.R.S.A. § 1580-H(9)(A) or 22 M.R.S.A. § 1580-H(9)(B). it is 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: cigarette fabricator physical plant address mailing address contact person telephone and facsimile numbers relationship to the applicant. identify the situs of the transfer of ownership and attach a copy of any agreement or contract between the applicant and fabricator   American LegalNet, Inc. www.FormsWorkflow.com Has the applicant has ever had a complaint filed against it or had any judgment entered against it in any State concerning MSA obligations? Yes No If yes, please provide a copy of the judgment or complaint. If a judgment has been paid, please provide evidence that the judgment amount has been paid in full. PART 2: BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) A. Participating Manufacturers The participating manufacturer identified in Part 1 has the following brand families, each of which the manufacturer hereby affirms are to be deemed its cigarettes and/or roll-your-own (RYO) for purposes of calculating its payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. Brand Families B. Non-Participating Manufacturers (attach additional sheets if necessary) The non-participating manufacturer identified in Part 1 has the following brand families1, each of which the manufacturer affirms are to be deemed its cigarettes or RYO for purposes of 22 M.R.S.A. §§ 1580-G, et seq. Attach a sample of the packaging and labeling for each Brand Family identified. Units Sold: Brand Family 2007 Units Sold: 2008 as of date of Certification Name and address of other manufacturers of brand family in preceding or current calendar year.2 C. Trademark Holder (for Participating Manufacturers and Non-Participating Manufacturers) If you are not the trademark holder(s) of any brand listed above, identify the following: Brand Name of Trademark Holder Contact Person Address Telephone                                                   1 You must list all brand families, not only those brand families sold in Maine. Indicate with an asterisk (*) those brand families that will not be sold in Maine.  2 All current manufacturers of a brand family must file a proper certification before a brand family will be included on the directory. If you are the exclusive manufacturer of the brand family, write the word “None” in this space. DO NOT LEAVE BLANK.  2  American LegalNet, Inc. www.FormsWorkflow.com PART 3: NON-PARTICIPATING MANUFACTURER ADDITIONAL INFORMATION A. Registered Agent for Service of Process Please certify as follows: The non-participating manufacturer identified in Part 1 is domiciled in the State of Maine. The non-participating manufacturer identified in Part 1 is a non-resident or foreign non-participating manufacturer that has registered to do business in the State of Maine as a foreign corporation or business entity. The non-participating manufacturer identified in Part 1 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 Fax Number E-mail Address Please attach proof of the appointment and availability of the Agent. B. Qualified Escrow Fund – Financial Institution Name of Institution Address Representative Name Telephone Number Escrow Account Number State Sub-Account Number Has the Escrow Agreement been approved by the Attorney General? ‫ٱ‬ ‫ٱ‬ Yes No By Whom Approval Date Please attach an executed copy of the current Non-Participating Manufacturer’s Escrow Agreement. C. Escrow Deposit/Withdrawal History for Maine (attach additional sheets if necessary) Date Deposit Total: Withdrawal* Total: Balance Total: Please attach copies of records of the financial institution confirming the foregoing. *Withdrawals must comply with 22 M.R.S.A. § 1580-I. Verification of compliance must be provided. 3  American LegalNet, Inc. www.FormsWorkflow.com D. Quarterly Payments Has the applicant has ever had a complaint filed against it or had any judgment entered against it in any State concerning non-compliance with escrow statutes? Yes No If yes, please provide a copy of the judgment or complaint. If a judgment has been paid, please provide evidence that the judgment amount has been paid in full. Has the applicant failed to pay escrow when due in any State? Yes No What was the amount not paid? $__________________________ Explain the current status. _________________________________________________________ E. Stamping Agents/Distributors Complete this section for each stamping agent/distributor selling manufacturer’s product in Maine. Distributor Distributor Address Brand PART 4: EXECUTION BY AUTHORIZED DESIGNEE 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   here ► ______________________________________     _______________________________  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:  ________________________________  Mail the completed certificate of compliance to: Maine Office of Attorney General 6 State House Station Augusta, Maine 04333-0006 Attention: Laurie Simpson 4  American LegalNet, Inc. www.FormsWorkflow.com