MONTANA DEPARTMENT OF JUSTICE 2011 Quarterly Certificate of Escrow Deposit Part 1: Non-Participating Manufacturer (NPM) Identification Company Name: Physical Address: Mailing Address (if different): Contact Person Name and Title: Telephone Number: FAX: E-mail Address: Name of retailer(s)/wholesaler(s) that sells your cigarettes or RYO in Montana and brand(s) sold: Part 2: Quarter Being Reported The sales year for this certificate is the calendar year 2011. The quarter being reported is (check one):  January 1, 2011 - March 31, 2011  April 1, 2011 - June 30, 2011  July 1, 2011 - September 30, 2011  October 1, 2011 - December 31, 2011 Part 3: Units Sold for the Quarter Indicated Indicate the number of individual cigarettes and units of “roll-your-own” tobacco sold by the manufacturer (whether directly or through a distributor, retailer, or similar intermediary or intermediaries) for the 2011 quarter indicated above and produce any and all documentation of the sale or transfer of cigarettes or RYO into Montana: A. __________________________ Part 4: Deposit Amount The deposit amount for 2011 is $.0282581 per unit sold.* B. $.0282581 Multiply line A by line B to calculate the total deposit due. This amount must be deposited in the Montana subaccount of the manufacturer’s qualified escrow account within 30 days after the end of the quarter indicated above. Mont. Code Ann. § 16-11-403(2)(a) requires payments to be “adjusted for inflation.” Mont. Code Ann. § 16-11-402(1) defines “adjusted for inflation” as “increased in accordance with the formula for inflation adjustment set forth in Exhibit C to the Master Settlement Agreement. Each year, this formula increases 3% or the actual inflation rate, whichever is greater. Because the actual inflation rate cannot be determined until the end of 2011, tobacco product manufacturers required to make quarterly escrow payments will be required, in their quarterly escrow payments, to deposit an amount that has been cumulatively adjusted for inflation by 3%. When the inflation rate for 2011 has been determined, manufacturers will be advised and then have until April 15, 2012, to deposit any additional money, if necessary, to satisfy the actual inflation amount under the Act. The 2010 inflation rate, increased by 3%, is 49.92446. Multiplying the 2010 base escrow deposit amount $.0188482, by the inflation rate, 49.92446%, equals the cumulative inflation adjustment amount of $.0094099. Adding the base escrow deposit amount, $.0188482, to the cumulative inflation adjustment amount, $.0094099, equals $.0282581. * Montana Department of Justice 2011 Quarterly Certificate of Escrow Deposit Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 5: Financial Institution Name of Financial Institution: Escrow Agent Contact Name and Title: Mailing Address: Telephone Number: Escrow Account Number: FAX: Montana Subaccount Number:_______________ Attach a copy of the financial institution’s receipt or other proof of deposit of the proper escrow payment. Part 6: Certification The above-named NPM certifies that (initial all four): It has previously submitted a Montana Certificate of Escrow Deposit to Attorney General’s Office. Date submitted: Its qualified escrow fund complies with Mont. Code Ann. § 16-11-403; Any escrow funds held or to be held in its qualified escrow fund on behalf of the State of Montana are or will be held in a separate segregated account, separate and apart from escrow funds held on behalf of any other beneficiary; and There is no security interest that has been granted in or has attached or is otherwise applicable to any escrow funds held or to be held in the above-named Non-Participating Manufacturer’s qualified escrow fund on behalf of the State of Montana. Part 7: Authorized Designee and Representation This document must be signed and dated by an authorized notary public as follows: Under penalty of perjury, I certify and declare that all of the statements and information contained in this 2011 Quarterly Certificate of Escrow Deposit, including attachments are true, correct, accurate and complete in every particular and that I am a person authorized to bind the above-named NPM making this Certification either under the laws of the State of Montana or of the jurisdiction where the manufacturer resides or is organized. Any violation of these requirements is a basis for removal of the above-named NPM and its brand families from the Tobacco Product Directory. Authorized Designee: Signature of Designee: Title: Date: SUBSCRIBED AND SWORN TO before me on this date: Signature of Notary Public: City or County of: Printed Name of Notary Public: My Commission expires: Seal: Mail the completed Certificate to: Mr. Zach Zipfel Montana Attorney General's Office 215 North Sanders P.O. Box 201401 Helena, MT 59620-1401 Montana Department of Justice AND Mr. Jim McKeon Miscellaneous Tax Program Manager Department of Revenue P.O. Box 5805 Helena, MT 59604-5805 2011 Quarterly Certificate of Escrow Deposit Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com