CATHERINE CORTEZ MASTO ATTORNEY GENERAL STATE OF NEVADA NON-PARTICIPATING MANUFACTURER (NPM) QUARTERLY CERTIFICATE OF COMPLIANCE Please type or print legibly. Any illegible certificate will be returned and deemed unfiled. PART 1: Company Name Address (Mailing and Physical) City/State/County Telephone Number Fax Number Email Website Name/Title of Person Completing Form Address of Manufacturing Plant(s) Name of Factory Manager(s) Phone Number of Factory Manager(s) Fax Number of Factory Manager(s) Email of Factory Manager(s) If located in U.S.: Manufacturer’s Federal Tax ID number If located in U.S.: TTB Tobacco Manufacturer Permit Number Expiration Date PART 2: LIABILITY REPORTING PERIOD The liability period for this Certificate and Affidavit is: (check one below) January 1 through March 31, 2011 – First Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before April 30, 2011 NPM Quarterly Certificate of Compliance received by Attorney General on or before May 10, 2011 Account letter submitted by bank to the Attorney General on or before May 10, 2011 April 1 through June 30, 2011 – Second Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before July 31, 2011 NPM Quarterly Certificate of Compliance received by Attorney General on or before August 10, 2011 Account letter submitted by bank to the Attorney General on or before August 10, 2011 July 1 through September 30, 2011 – Third Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before October 31, 2011 NPM Quarterly Certificate of Compliance received by Attorney General on or before November 10, 2011 Account letter submitted by bank to the Attorney General on or before November 10, 2011 October 1 through December 31, 2011 – Fourth Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before January 31, 2012 NPM Quarterly Certificate of Compliance received by Attorney General on or before February 11, 2012 Account letter submitted by bank to the Attorney General on or before February 11, 2012 American LegalNet, Inc. www.FormsWorkFlow.com PART 3: QUARTERLY BRAND SALES BRAND FAMILY NAME & STYLES CIGARETTES OR RYO (check boxes) Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Report Units sold in Sticks for Cigarettes or in Ounces for RYO RYO PART 4: WORKSHEET FOR CIGARETTES SOLD DURING LIABILITY REPORTING PERIOD 1. Show on Line A, the total units sold by non-participating manufacturer in Nevada for the quarter calendar reporting period (for RYO conversion to stick units: RYO Ounces ÷ .09 and then round UP to next whole unit). A. ____________ (Units sold) 2. Line B: Multiply Line A (Units Sold) by the 2011 applicable base rate of $0.0188482. B. $___________ 3. Line C: Multiply Line A (Units Sold) by the 2011 preliminary inflation adjustment of $0.0094099. C. $___________ 4. Line D: Add Lines B and C for the TOTAL Escrow Amount required to be deposited for this reported calendar quarter: D. $____________ PART 5: CERTIFICATION OF ESCROW ACCOUNT AND AGREEMENT NOTE: The NPM certifies that it has established and continues to maintain a fully funded, qualified escrow account, pursuant to Chapters 370 and 370A of the Nevada Revised Statutes. Name of Financial Institution (Escrow Agent) Mailing Address Contact Person Contact E-mail Telephone number Fax Number Escrow Account Number Nevada Sub-Account Number American LegalNet, Inc. www.FormsWorkFlow.com PART 6: ADDITIONAL INFORMATION Answer all of the following questions: A. The registered agent identified on this NPM’s most recent Annual Certification submission continues to be the registered agent for this NPM: B. YES NO YES NO The escrow agreement provided with this NPM’s most recent Annual Certification remains in force and unchanged: D. NO The financial institution information provided on this NPM’s most recent Annual Certification remains accurate: C. YES If the answer to A, B and/or C above is NO, explain below and provide supporting documentation: American LegalNet, Inc. www.FormsWorkFlow.com PART 7: AFFIDAVIT OF NPM An authorized officer of the NPM must sign this form, and this form MUST be notarized. Under penalty of falsification, I state that the NPM named in Part 1, as of the date of this certification, is a nonparticipating manufacturer in full compliance with all applicable sections of NRS Chapters 370 and 370A. This certification must be signed by a qualified company officer authorized to bind the applicant company. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand that the Nevada Attorney General may require additional information and/or documentation relative to the assertions made in this Quarterly Certificate of Compliance. I have examined this Certificate, including attachments and supporting documents and, to the best of my knowledge and belief, this certification, including attachments and supporting documents, is true, correct, and complete. By signing this affidavit on behalf of the applicant company, I understand that the company is required to comply with state and federal laws concerning the sale of tobacco products. Name of Officer of NPM (print) Title Signature of Officer of NPM Date Subscribe and sworn to this date: ____________________________________________________________________ County of: ______________________________________________________________________________________ Signature of Notary Public: _________________________________________________________________________ Notary Commission Expires: ________________________________________________________________________ Mail this completed Certificate of Compliance and attachments, along with the original executed and notarized Affidavit of Tobacco Product Manufacturer (PART 7), to: Nevada Attorney General’s Office Attn: Alicia Lerud, Deputy Attorney General Tobacco Enforcement Division 100 North Carson Street Carson City, Nevada 89701 Telephone: (775) 684-1124 Fax: (775) 684-1275 alerud@ag.nv.gov American LegalNet, Inc. www.FormsWorkFlow.com