CERTIFICATE OF COMPLIANCE With MD Code Ann. Bus. Reg. §§16-401 to 16-403 Calendar Year 2010 For instructions and definition of terms, refer to the accompanying letter and copy of MD Code Ann. Bus. Reg. §§16-401 et seq. 1. Nonparticipating Manufacturer’s Identification Name: _______________________________________________________ Address: _______________________________________________________ _______________________________________________________ Phone: 2. ______________________ Fax: ___________________________ Status as Tobacco Product Manufacturer Selling in Maryland In 2010, the manufacturer was a tobacco product manufacturer that sold cigarettes to consumers in Maryland, directly or through a distributor, retailer, or similar intermediary. Yes ___________________ No__________________ If the answer is no, please go to Part 7, sign and submit this form. If the answer is yes, you are obligated to set up a qualifying escrow account, and deposit the appropriate funds. 3. Units sold In calendar year 2010, the manufacturer sold the following number of individual cigarettes and “roll-your-own” tobacco in Maryland. ____________________________________ 4. Escrow rate and payment The unadjusted escrow rate for 2010 is $0.0188482. The inflation adjustment multiplier for 2010 is 45.55773%. The escrow rate adjusted for inflation is $0.0274350. American LegalNet, Inc. www.FormsWorkFlow.com Number of cigarettes sold (from #3) __________________________ Inflation-adjusted escrow rate (from #4) x $0.0274350 Total: Amount to be deposited in escrow $__________________________ 5. Financial Institution Name of Institution: Address of Institution: ____________________________________________ ____________________________________________ ____________________________________________ Phone Number: ____________________________________________ Account Number: ____________________________________________ Date Account Opened: ____________________________________________ Total Amount Held for State of Maryland: $_______________________________ 6. Documentation If this is your initial deposit, attach a copy of your executed escrow agreement, and copies of amendments, if any, to your escrow agreement. For all deposits, attach copies of your receipt or other proof of deposit from your institution. 7. Certification I certify that the above information is true and correct. Signature of Authorized Agent: Name of Authorized Agent: Title of Authorized Agent: Date: 8. ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Mail this certificate of compliance to: David S. Lapp, Assistant Attorney General Office of the Attorney General of Maryland 200 St. Paul Place, 20 th Floor Baltimore, Maryland 21202 American LegalNet, Inc. www.FormsWorkFlow.com