CATHERINE CORTEZ MASTO ATTORNEY GENERAL STATE OF NEVADA TOBACCO MANUFACTURER CERTIFICATE OF COMPLIANCE Please type or print. PART 1: A. TOBACCO PRODUCT MANUFACTURER IDENTIFICATION Complete company information below: Company Name Address City/State/Zip/Country Telephone Number Fax Number E-Mail Address 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) If located in U.S.:Manufacturer’s Federal Taxpayer ID number: If located in US: TTB Tobacco Manufacturer Permit Number B. Expires The tobacco product manufacturer identified above, as of the date of this Certification, is (check one below): A participating manufacturer [Complete Parts 1, 2A and 6] A non-participating manufacturer [Complete entire form except 2A] This form is (check one below): Initial Certification – Manufacturer is not currently listed on the Nevada Tobacco Directory. Annual Certification – Due April 30, 2011 for Nevada sales in 2010. Supplemental Certification – Change of information provided to the Attorney General. Change of information must be submitted 30 days prior to change. NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 1 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com PART 2: A. BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) Participating Manufacturers The participating manufacturer identified in Part 1 has the following brand families, each of which the manufacturer hereby affirms are to be deemed its cigarettes for the purposes of calculating its payments under the Master Settlement Agreement, in the volume and shares determined pursuant to the Master Settlement Agreement. Indicate with an asterisk (*) those brands not being sold in current year. Attach additional sheet if necessary. Brand Family Name Cigarettes or RYO Cigarette RYO Brand Family Name Cigarettes or RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO I. For the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Telephone: 202-326-2222 http://www.ftc.gov II. Provide a copy of the current Centers for Disease Control (CDC) ingredient-listing (cigarettes only) compliance letter(s) pertaining to the above brands of cigarettes for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 2 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com B. Non-Participating Manufacturers The non-participating manufacturer identified in Part 1 has the following brand families, each of which the tobacco product manufacturer affirms are to be deemed its cigarettes for purposes of Nevada Revised Statute (NRS) Chapters 370 and 370A. List all brand families sold in the preceding calendar year and at any time in the current calendar year. Indicate by an asterisk (*) any brand no longer being sold in Nevada as of the date of this certification. 0.09 ounce of RYO constitutes one unit. Attach additional sheets if necessary. Brand Family Name Cigarettes or Roll-Your-Own Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Previous Manufacturer (Name & Address) RYO Cigarette Units Sold RYO Provide a sample of the packaging of each brand family. Check here if previously supplied packaging samples have not changed. NOTE: If the manufacturer has previously supplied such packaging to the Attorney General and if such packaging has not changed, samples need not be supplied this year. I. For the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Telephone: 202-326-2222 http://www.ftc.gov II. Provide a copy of the current Centers for Disease Control (CDC) ingredient-listing (cigarettes only) compliance letter(s) pertaining to the above brands of cigarettes for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 3 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com PART 3: DISTRIBUTOR AS IDENTIFIED IN NRS CHAPTER 370 List below the names and addresses of Nevada licensed distributors selling, or intending to sell, product(s) manufactured by the non-participating manufacturer identified above in Part 1. Attach additional sheet if necessary. Distributor Name PART 4: Distributor Address Phone No. Brand NON-PARTICIPATING MANUFACTURER REGISTERED AGENT Check one below: The non-participating manufacturer identified in Part 1 is registered to do business in Nevada. The non-participating manufacturer identified in Part 1 has appointed and continues to engage the following agent located in Nevada. A current (dated this year) original letter from the registered agent accepting this appointment must be attached. Name of Registered Agent Address City/State/Zip Telephone Number Fax Number NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 4 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com PART 5: A. NON-PARTICIPATING MANUFACTURER QUALIFIED ESCROW ACCOUNT Escrow Account Information The non-participating manufacturer identified in Part 1 has established and continues to maintain the following qualified escrow fund under NRS Chapter 370A.: Name of Financial Institution Address City/State/Zip/Country Contact Name/Title Telephone Number Escrow Account Number Fax Number Nevada Sub-Account Number Provide an executed copy of the Non-Participating Manufacturer’s current Escrow Agreement. Any amendments or attachments to such agreements MUST also be provided. B. Escrow calculation and deposit for sales in Nevada in 2010 1. Show on Line A the total units sold by NPM in Nevada during the calendar year 2010 (for RYO sticks divide RYO ounces by .09 and round A. up to next whole unit): (units) 2. Multiply Line A by the applicable rate per unit sold in 2010 of $0.0188482: B. $ 3. Multiply Line A by the final inflation adjustment per unit sold of $0.0085868: C. $ 4. Add Lines B and C for the TOTAL amount required to be deposited for the calendar year 2010: D. $ 5. Subtract quarterly deposits previously made for 2010 sales: E. $ 6. Total deposit required to be made by April 15, 2011 for 2010 sales: F. $ NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 5 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com C. Complete Escrow Deposit/Withdrawal History for the State of Nevada (attach additional sheets if necessary): Withdrawals must comply with NRS Chapter 370A and verification of compliance must be provided. Date Deposit Total: D. Withdrawal Total: Balance Total: The Financial Institution noted in Part 5 of this certification is required to provide directly to the Tobacco Enforcement Division of the Nevada Attorney General’s Office the following: I. Proof of amount and date of deposit to Nevada’s segregated sub-account for 2010 sales. II. Current account ledger of the tobacco product manufacturer’s segregated subaccount for Nevada. NOTE: These items are part of the NPM Annual Certification and are due by April 30, 2011. Mail this completed Certificate of Compliance and attachments, along with the original executed and notarized Affidavit of Tobacco Product Manufacturer (Section 6), to: Nevada Attorney General’s Office Tobacco Enforcement Division Attn: Alicia Lerud, Deputy Attorney General 100 North Carson Street Carson City, Nevada 89701 775-684-1124 alerud@ag.nv.gov NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 6 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com PART 6: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER An authorized officer of the tobacco product manufacturer MUST sign this form and check one box below. This form MUST be notarized. Under penalty of perjury, I certify that the tobacco product manufacturer named in Part 1 A, as of the date of this certification, is a participating 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 Attorney General may require additional information and/or documentation to determine if applicant qualifies for listing on the Nevada Directory. I have examined this certification, 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. Under penalty of perjury, I certify that the tobacco product manufacturer named in Part 1A, as of the date of the certification, is a non-participating 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 Attorney General may require additional information and/or documentation to determine if applicant qualifies for listing on the Nevada Directory. I have examined this certification, 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 Tobacco Product Manufacturer (print name) Title __________________________________________________________________________________ Signature of Officer Date Subscribed and sworn to this date:_______________________________________________________ County of: _________________________________________________________________________ Signature of Notary Public: ____________________________________________________________ Notary Commission expires: ___________________________________________________________________ NOTE: The State of Nevada will not process incomplete or illegible certifications. Page 7 of 7 NVAGO 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com