Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 1 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 MONTANA DEPARTMENT OF JUSTICE Tobacco Product Manufacturer Certificate of Compliance Annual Renewal Initial Supplemental Sales Year: 2018 PLEASE TYPE OR PRINT IN PERMANENT BLUE INK PART I: GENERAL BUSINESS AND OWNERSHIP INFORMATION 1. Applicant Tobacco Product Manufacturer Identification Applicant: Physical Address (street address only - no post office box): Mailing Address (if different from above): Phone Number: Facsimile (FAX) Number: E-mail Address: Website Address: Name/Title of Person Completing Certification: Manufacturing Plant(s) Name and Street Address (if different from above): Manufacturing Plant Phone Number: Manufacturing Plant FAX Number: Name/Title/Phone Number of Person at Plant if different from above: (Attach additional sheet(s), as necessary, to provide a complete response.) 2. The undersigned certifies that as of the date of this Certification, the above-named Applicant is: (initial one) a Participating Manufacturer (PM). a Non-Participating Product Manufacturer (NPM) in full compliance with Montana's Tobacco Product Reserve Fund Statute, Mont. Code Ann.247 16-11-403, and implementing regulations, including having made all required deposits into a Qualified Escrow Fund for all years beginning with year 1999 sales. 3. Applicant is the manufacturer (i.e., fabricator) of the brands listed 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. Yes No Please attach photographs of the exterior and interior of the manufacturing facility and a photograph/diagram indicating where the equipment & facilities for manufacturing (i.e., fabricating) the cigarettes, if any, are located. American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 2 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 4. Applicant 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. Yes No If the answer is "Yes," identify each cigarette manufacturer (i.e., fabricator), its plant street address, mailing address, contact person, telephone and fax numbers, and the relationship to Applicant. Identify the location of the transfer of ownership of cigarettes and include a copy of every agreement or contract between Applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 5. Applicant is a successor of an entity described in questions 3 or 4 above (i.e., manufacturer or first importer). Yes No 6. If Applicant answered "No" to questions 3, 4, and 5 above, explain the basis for Applicant's claim that it is a Tobacco Product Manufacturer (TPM) as defined under Mont. Code Ann. 247 16-11-402(9) and submit all documentation to support Applicant's contention. Attach additional sheet(s), as necessary, to provide a complete response. 7. Licenses/Permits. a. U.S. Treasury, Tobacco Tax Bureau (TTB) Permit Number as a manufacturer: and/or as an importer: . Attach a copy of Applicant's current permit as a manufacturer or importer pursuant to 26 U.S.C. Chapter 52, and regulations issued thereunder. b. Name of any other foreign permit or license and date of expiration . American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 3 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 PART II: BRAND FAMILY IDENTIFICATION 1. Brand Family Identification (PMs complete column A. PMs affirm that each brand family listed is to be considered its cigarettes for purposes of calculating its payments under the MSA for the relevant year, in the volume and shares determined pursuant to the MSA. NPMs complete columns A through C. NPMs affirm that each brand family listed is to be considered its cigarettes for purposes of Mont. Code Ann. 247 16-11-403.) A. Brand Family (Indicate with an asterisk (*) those brands that will not be sold in 201 8 ) B. Units Sold in Preceding Calendar Year C. Units Sold this calendar year to date. D. Manufacturer of Brands Listed (Include complete address information) Attach additional sheet(s), as necessary, to provide a complete response. Attach actual samples or digital copies of the packaging and labeling for each brand of cigarettes that Applicant intends to sell in Montana. If you have already provided samples of a brand, you do not need to provide another sample unless the packaging or labeling has changed from the sample you already provided. Acknowledge No Changes to Packaging 2. Current Trademark Holder(s) Provide the name, address and phone number of the current trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical Address Phone Attach additional sheet(s), as necessary, to provide a complete response. Attach Licensing Agreement if Applicant is not the Trademark holder. American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 4 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 3. Prior Trademark Holder(s) Provide the name, address and phone number of the prior trademark holder(s) of each brand listed above. Brand Trademark Holder and Contact Person Physical Address Phone Attach additional sheet(s), as necessary, to provide a complete response. 4. UPC Code(s) Provide the UPC Codes for cigarettes (packs & cartons), RYO, and the UPC holder(s) name and contact for each brand listed above. Brand / S t y l e Cigarette Pa cks & Cartons UPC Codes RYO UPC Codes UPC Holder & Contact Person Attach additional sheet(s), as necessary, to provide a complete response. American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 5 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 PART III: MANUFACTURING AND COMPLIANCE INFORMATION 1. Manufacturer(s) For each Brand Family, list the name and address of the manufacturer (i.e., fabricator) of the cigarettes, if other than Applicant. Include all company names and addresses used by the manufacturer(s) in making cigarettes for sale in the United States. Brand Manufacturer (i.e., fabricator) Street Address Attach additional sheet(s), as necessary, to provide a complete response. 2. Health Warning Rotation Plan For each Brand Family, list the name and address of the entity that filed a Cigarette Health Warning Rotation Plan with the Federal Trade Commission before the cigarettes were distributed into the United States. Brand Filer Street Address For each brand, attach the Federal Trade Commission's written approval of Applicant's annual Cigarette Health Warning Rotation Plan. Attach additional sheet(s), as necessary, to provide a complete response. 3. Ingredient Reporting For each Brand Family, list the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act. Brand Submitter Street Address Attach copies of all Certificates of Compliance received from the U.S. Health and Human Services for Applicant's annual ingredient reporting required by the Federal Cigarette Labeling and Advertising Act. (15 U.S.C. 247 1335a). Attach additional sheet(s), as necessary, to provide a complete response. American LegalNet, Inc. www.FormsWorkFlow.com Montana Department of Justice Tobacco Product Manufacturer Certificate of Compliance Page 6 of 17 Revised February 2018 Montana Code Annotated Title 16, Chapter 11, Parts 4 and 5 4. Cigarette Packaging For each Brand Family, list the name and address of person, company, or entity that placed the cigarettes into packages with the U.S. Surgeon G