Missouri Department of Revenue Taxation Division P.O. BOX 811 Jefferson City MO 65105-0811 FORM 5302 ANNUAL ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Non-Participating Manufacturers) (REV. 04-2011) PART 1: SALES YEAR SALES YEAR _________________ PART 2: MANUFACTURER IDENTIFICATION FEDERAL I.D. NUMBER COMPANY NAME __ __ __ __ __ __ __ __ __ MAILING ADDRESS CITY STATE ZIP CODE COUNTRY __ __ __ __ __ PHYSICAL ADDRESS CITY STATE ZIP CODE COUNTRY __ __ __ __ __ TELEPHONE NUMBER (__ __ __) __ __ __ - __ __ __ __ FAX NUMBER (__ __ __) __ __ __ - __ __ __ __ E-MAIL ADDRESS PART 3: UNITS SOLD BRAND FAMILY (Do not separately list styles within a brand family such as Regular, Menthol, Light, 100s, etc.)* CIGARETTES (C) or RYO (RYO) Number of Units (STICKS) Sold During the SALES YEAR (FOR RYO, STICKS = OUNCES ÷ .O9) *By including a brand family in its certification, a Non-Participating Manufacturer affirms that the brand family listed is deemed to be its cigarettes for escrow purposes for the year indicated in Part 1 of this form. However, the Director of Revenue retains the discretion to determine whether the brand family constitutes the cigarettes of another tobacco product manufacturer. Page 1 of 2 DOR-5302 (04-2011) American LegalNet, Inc. www.FormsWorkFlow.com PART 4: CALCULATION OF ESCROW DEPOSIT AMOUNT USE THE RATES BELOW TO FIGURE THE APPROPRIATE DEPOSIT AMOUNT. ESCROW DUE/SALES YEAR: $.0094241 per unit sold after July 1, 1999 (effective date of the Act) plus inflation of 3%; For 2000: $.0104712 plus inflation of 6.48841% per unit sold: For 2001: $.0136125 plus inflation of 9.68306% per unit sold: For 2002: $.0136125 plus inflation of 12.97355% per unit sold: For 2003: $.0167539 plus inflation of 16.36276% per unit sold: For 2004: $.0167539 plus inflation of 20.15102% per unit sold: For 2005: $.0167539 plus inflation of 24.25497% per unit sold: For 2006: $.0167539 plus inflation of 27.98262% per unit sold: For 2007: $.0188482 plus inflation of 33.20594% per unit sold: For 2008: $.0188482 plus inflation of 37.20212% per unit sold: For 2009: $.0188482 plus inflation of 41.31818% per unit sold: For 2010: $.0188482 plus inflation of 45.55773% per unit sold for a total of $.0274350 per unit sold. Number of Units (Sticks) Sold : ___________________ Units Sold times the appropriate rate above: $ ___________________ Escrow Deposit for State of Missouri: $ ___________________ _ _ / _ _ / __ __ __ __ Escrow Deposit Date: PART 5: FINANCIAL INSTITUTION FINANCIAL INSTITUTION AUTHORIZED CONTACT NAME AND TITLE ADDRESS CITY STATE TELEPHONE NUMBER FAX NUMBER (__ __ __) __ __ __ - __ __ __ __ ZIP CODE __ __ __ __ __ (__ __ __) __ __ __ - __ __ __ __ E-MAIL ADDRESS PRIMARY ESCROW ACCOUNT NUMBER MISSOURI SUB-ACCOUNT NUMBER(S) TOTAL FUNDS HELD IN SEPARATE ACCOUNT FOR MISSOURI $ DATE ESCROW WAS ESTABLISHED DATE OF LAST AMENDMENT TO ESCROW AGREEMENT __ __ / __ __ / __ __ __ __ __ __ / __ __ / __ __ __ __ Attached is a copy of the financial institution’s receipt or other proof of deposit of the proper escrow payment. Attached is an executed copy of the Escrow Agreement with all amendments and attachments. PART 6: SIGNATURE Under penalty of perjury, I declare that I am authorized to certify on behalf of the Tobacco Manufacturer in Part 2 that all of the information contained in this Escrow Compliance Certificate, including but not limited to the attachments herewith, are true, complete and accurate. This Escrow Compliance Certificate must also be signed and dated by an authorized notary public. Name (Print) _____________________________________________________________ Title _______________________________________________ Signature _____________________________________________________________________________________ Date __ __ / __ __ / __ __ __ __ NOTARY PUBLIC (SIGNATURE MUST BE NOTARIZED) NOTARY PUBLIC EMBOSSER OR BLACK INK RUBBER STAMP SEAL STATE COUNTY (OR CITY OF ST. LOUIS) SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF 20 NOTARY PUBLIC SIGNATURE MY COMMISSION USE RUBBER STAMP IN CLEAR AREA BELOW. EXPIRES NOTARY PUBLIC NAME (TYPED OR PRINTED) Mail the completed certificate of compliance to: Missouri Department of Revenue Taxation Division P.O. Box 811 301 W. High Street, Room 330 Jefferson City, MO 65105-0811 573-751-7163 DOR-5302 (04-2011) And Missouri Attorney General P.O. Box 899 227 W. High Jefferson City, MO 65102 573-751-3321 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com