Page 1 of 5 NVAGO 226 Tobacco Unit Form Revised: 3/1 /2019 STATE OF NEVADA OFFICE OF THE ATTORNEY GENERAL 5420 Kietzke Lane, Suite 202 Reno, Nevada 89511 NON-PARTICIPATING MANUFACTURER (NPM) QUARTERLY CERTIFICATE OF COMPLIANCE FORM B&TD-TOB3 A. Company Information Company Name Address City/State/Zip/Country Telephone Number Website Name/Title of Company Contact Company Contact E - Mail Address First Quarter: January 1 through March 31, 2019 April 30, 2019: May 10, 2019: Escrow deposit to Nevada sub-account. NPM Quarterly Certificate of Compliance received by Attorney General. May 10, 2019: Account letter submitted by bank to the Attorney General. Second Quarter: April 1 through June 30, 2019 July 31, 2019: Escrow deposit to Nevada sub-account. August 10, 2019: NPM Quarterly Certificate of Compliance received by Attorney General. August 10, 2019: Account letter submitted by bank to the Attorney General. Third Quarter: July 1 through September 30, 2019 October 31, 2019: Escrow deposit to Nevada sub-account. November 10, 2019: NPM Quarterly Certificate of Compliance received by Attorney General. November 10, 2019: Account letter submitted by bank to the Attorney General. Fourth Quarter: October 1 through December 31, 2019 January 31, 2020: Escrow deposit to Nevada sub-account. February 10, 2020: NPM Quarterly Certificate of Compliance received by Attorney General. February 10, 2020: Account letter submitted by bank to the Attorney General. NOTE: The failure to submit this certificate by the applicable deadlines may result in the assessment of a civil penalty up to $1,000 per day. Further, it is the responsibility of the NPM to accurately report Units Sold in NV and deposit the appropriate escrow. Inaccuracies will result in civil penalties. PART I: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION PART II: LIABILITY REPORTING PERIOD American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 NVAGO 226 Tobacco Unit Form Revised: 3/1 /2019 NPM QUARTERLY CERTIFICATE OF COMPLIANCE FORM B&TD - TOB3 Provide the total Units Sold (cigarettes & Roll-Your-Own tobacco) by the NPM in Nevada during the quarter. This total includes Units Sold by the NPM on tribal land located in Nevada during the quarter. Brand Family Name Distributor Name/City/State Total Sticks of Cigarettes Sold This Quarter Bearing Nevada Cigarette Stamps Total Ounces of RYO Tobacco Sold During This Quarter Subtotal of RYO Ounces N/A Total Quarter Stick Counts (RYO oz to stick conversion: .09 oz = 1 stick) Total Combined Sticks Sold (Cigarette sticks + RYO sticks sold this quarter) PART III: QUARTERLY UNITS SOLD TOTAL American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 NVAGO 226 Tobacco Unit Form Revised: 3/1 /2019 NPM QUARTERLY CERTIFICATE OF COMPLIANCE FORM B&TD - TOB3 A.Escrow Account Information The NPM identified in Part I has established and continues to maintain the followingqualified escrow fund as required by NRS Chapter 370A: Name of Financial Institution Address City/State/Zip/Country Escrow Agent Contact Name/Title Telephone Number Email Escrow Account Number Nevada Sub - Account Number B.Quarterly Escrow Calculation for 2019 Sales A. (units) B.$ 0.0357965 Enter on Line A the total sticks sold by the NPM in Nevada during thequarter, including sales on tribal land (Units Sold) from page 2.Line B contains the applicable rate per Unit Sold in 2019($0.0188482) plus the inflation adjustment for 2019 ($0.0169483).Multiply Line A and B and enter the total escrow due for the quarter. C. Any required escrow payment for the quarter must be deposited into the segregated Nevada sub-account by the due date indicated in Part II. You must ensure your escrow agent provides proof of the deposit to the Attorney General222s Office no later than the deadline to submit this quarterly certificate of compliance. Failure to deposit the correct amount of escrow may result in civil penalties and/or removal from the NV Tobacco Directory. The Financial Institution/Escrow Agent noted above is required to provide directly to the Tobacco Enforcement Unit of the Nevada Attorney General222s Office the following: 1.Proof of amount and date of deposit to Nevada222s segregated sub-account for the 2019quarterly sales. 2.A current account ledger of the tobacco product manufacturer222s segregated sub-accountfor Nevada. PART IV: QUARTERLY ESCROW CALCULATION American LegalNet, Inc. www.FormsWorkFlow.com NPM QUARTERLY CERTIFICATE OF COMPLIANCE FORM B&TD - TOB3 NVAGO 226 Tobacco Unit Form Revised: 3/1/2019 Page 4 of 5 A. The Registered Agent identified in the NPM222s most recent Annual Certification has changed since that certification. Yes No B. The financial institution provided in the NPM222s most recent Annual Certification has changed since that certification. Yes No C. The Escrow Agreement provided in the NPM222s most recent Annual Certification has changed since that certification. Yes No D. The most recently executed bond remains in effect and does not need to be increased per NRS 370.682. Yes No E. The NPM has submitted all monthly PACT Act reports to the Nevada Attorney General222s Office and the Nevada Department of Taxation for this quarter. Yes No F. The NPM has submitted all signed monthly NRS 370.327 reports, if required, to the Nevada Attorney General222s Office for this quarter. Yes No G. If the NPM responded 221Yes222 to A, B, or C above under Part V, please provide this new information immediately to the Nevada Attorney General222s Office. H. If the NPM responded 223No224 to D, E or F above under Part V, please attach an explanation. PART V: ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com NVAGO 226 Tobacco Unit Form Revised: 3/1/2019 Page 5 of 5 NPM QUARTERLY CERTIFICATE OF COMPLIANCE FORM B&TD - TOB3 P A R T VI: AFFIDAVIT OF TOBACCO MANUFACTURER An authorized officer of the NPM MUST sign this form under penalty of perjury. I certify that: The NPM named in Part I is in full compliance with all applicable sections of NRS Chapters 370 and 370A; I am an authorized officer of the NPM. Through my position with the NPM I am authorized to certify on behalf of the NPM and can legally bind the NPM; I understand that the Nevada Attorney General may require additional information and/or documentation to determine the veracity of assertions and representations made in this certification; I have examined this certification, including attachments and supporting documents, and, to the best of my knowledge and belief, this certification is true, correct, and complete; I understand that under Nevada Chapter 370.670(2), the NPM is required to maintain all invoices, documentation of sales, and any other documentation relied upon in making this certification for a period of five years from the date this certification is executed; By signing this affidavit on behalf of the NPM I understand that the NPM is required to comply with state and federal laws concerning the sale of tobacco products. I declare under penalty of perjury under the law of Nevada that the foregoing is true and correct. Name of Officer Title Electronic/Signature of Officer Date Email this completed Certificate of Compliance and any attached exhibits to the Nevada Attorney General222s Office - Tobacco Enforcement Unit: Email: tobaccoenforcement@ag.nv.gov PART V I : A FFIDAVIT OF TOBACCO MANUFACTURER American LegalNet, Inc. www.FormsWorkFlow.com