Maine - 2010 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 A. 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) B. Has the applicant ever had a complaint filed against it or had any judgment entered against it in any State Yes No concerning MSA obligations or non-compliance with escrow statutes? If yes, please provide a copy of the judgment or complaint. C. If the applicant is a Non-Participating Tobacco Product Manufacturer, the named applicant is: (check one) 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. 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 mailing address contact person telephone and facsimile numbers relationship to the applicant. ATTACH A COPY OF ANY AGREEMENT OR CONTRACT BETWEEN THE APPLICANT AND FABRICATOR other. Please explain   American LegalNet, Inc. www.FormsWorkFlow.com PART 2: BRAND IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) A. Participating Manufacturers The participating manufacturer identified in Part 1 has the following brand styles, 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 Styles B. Non-Participating Manufacturers (attach additional sheets if necessary) The non-participating manufacturer identified in Part 1 has the following brand styles1, 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 Style identified. Units Sold: Brand Style 2009 Units Sold: 2010 as of date of Certification Name and address of other manufacturers of brand style 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 styles, not only those brand styles sold in Maine. Indicate with an asterisk (*) those brand styles that will not be sold in Maine.  2 All current manufacturers of a brand must file a proper certification before a brand will be included on the directory. If you are the exclusive manufacturer of the brand style, 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 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 Has the Escrow Agreement been approved by the Attorney General? Telephone Number ‫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. D. Stamping Agents/Distributors Complete this section for each stamping agent/distributor selling manufacturer’s product in Maine. You must have a Maine licensed distributor to sell in Maine. Failure to identify such a distributor may result in delay of certification or conditional certification. Distributor Distributor Address Brand 3  American LegalNet, Inc. www.FormsWorkFlow.com 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: Jennifer Willis, AAG 4  American LegalNet, Inc. www.FormsWorkFlow.com