State of New Hampshire Quarterly Certification of Compliance by Non-Participating Manufacturer Regarding Escrow Payment Sales Year 2011 GENERAL INFORMATION What is the definition of a tobacco product manufacturer? • Any entity that manufactures cigarettes anywhere that such manufacturer intends to be sold in the United States, including cigarettes that are intended to be sold in the United States through an importer; • 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; or • Any successor of any entity described above. Who is required to file this affidavit? • Any tobacco product manufacturer that: 1. sells cigarettes to consumers within the state of New Hampshire (whether directly or through any distributor, retailer, or similar intermediary); and 2. has not become a participating manufacturer in the tobacco Master Settlement Agreement. You must file this affidavit to report the units of cigarettes you sold and pay the amount calculated into your qualified escrow fund. What is a non-participating manufacturer? A non-participating manufacturer is any tobacco product manufacturer who has not signed onto the tobacco Master Settlement Agreement, executed on 11/23/98 between 46 U.S. States, including New Hampshire, and certain tobacco companies. What is a qualified escrow fund? You are required to establish a qualified escrow fund. This means an escrow arrangement with a federally or statechartered financial institution having no affiliation with any tobacco product manufacturer and having assets of at least $1,000,000,000, where such arrangement (1) requires that the financial institution hold the escrowed funds’ principal for the benefit of the state of New Hampshire and other “releasing parties” as defined in the Master Settlement Agreement, or 25 years, whichever occurs first, and (2) prohibits you from using, accessing, or directing the use of the funds’ principal except as consistent with NH RSA 541-C. When is this affidavit due? The affidavit is due on the schedule set forth at Part 2 below. When must I make my escrow payment? See Part 2 below. SPECIFIC INSTRUCTIONS Part 1: Manufacturer’s Identification Write your name, address and telephone and fax number. Part 2: Sales Year and Quarter The sales year is 2011. Payments for each quarter are due no later than the end of the following quarter, with the exception of the fourth quarter payment. The certification of compliance is due on the same date. Thus, payments and certificates of compliance are due as follows: 1st quarter: no later than June 30, 2011; 2nd quarter: no later than September 30, 2011; 3rd quarter: no later than December 31, 2011; and 4th quarter: no later than April 15, 2012. Part 3: Units Sold Write the total number of individual cigarettes, including the amount of “roll-your-own” tobacco (.09 ounces constitutes one cigarette), sold during the quarter bearing New Hampshire cigarette stamps. On Schedule A, provide an itemized list by brand, wholesaler, or importer, as applicable, of all cigarettes included in the certification total reported at Part 3. Part 4: Deposit Amount Write the appropriate rate for the sales year. Write the amount you paid into your qualified escrow fund. Multiply the units of cigarettes by the appropriate rate and write the amount. The Inflation factor for quarterly payments is estimated based on a 3% inflation rate. If necessary, that rate will be adjusted in connection with the April 15, 2012 payment. Part 5: Financial Institution Write the name and address of the financial institution holding your escrow account. Include your escrow account number. Also write the total cumulative amount currently in your escrow account. Part 6: Signature An authorized notary public must also sign and date this affidavit. American LegalNet, Inc. www.FormsWorkFlow.com Certification of Compliance by Non-Participating Manufacturer Regarding Escrow Payment Sales Year 2011 Part 1: Manufacturer’s Identification Name: Address: State of New Hampshire Phone: Fax: Email Address: Part 2: Sales Year 2011/Quarterly Payments 2nd Quarter 3rd Quarter The Period of Sales for this Affidavit is: 1st Quarter th 4 Quarter Part 3: Units Sold Number of individual cigarettes, including “roll-your-own” tobacco, sold by the Manufacturer identified above during the sales period bearing New Hampshire cigarette tax stamps is as follows: (see instructions for details) ____________________________________________________________________________________ Part 4: Deposit Amount For the sales year: (Use the rates listed below to figure the appropriate deposit amount) Sales year 1999 (payable April 15, 2000) Sales year 2000 (payable April 15, 2001) Sales year 2001 (payable April 15, 2002) Sales year 2002 Sales year 2003 Sales year 2004 Sales year 2005 (payable quarterly) Sales year 2006 (payable quarterly) Sales year 2007 (payable quarterly) Sales Year 2008 (payable quarterly) Sales Year 2009 (payable quarterly) Sales Year 2010 (payable quarterly) Statutory Rate Per Cigarette $.0094241 $.0104712 $.0136125 $.0136125 $.0167539 $.0167539 $.0167539 $.0167539 $.0188482 $.0188482 $.0188482 $.0188482 Inflation Adjusted Rate Per Cigarette $.0097068 $.0111506 $.0149306 $.0153785 $.0194953 $.0201300 $.0208176 $.0214421 $.0251069 $.0258601 $.0266359 $.0274350 The appropriate rate for the 2011 sales year is 0.0282581 (estimated) This is the amount that has been paid into the qualified Escrow Account by the Manufacturer identified above (Multiply units in Part 3 by the appropriate rate in Part 4) $ Note: Attach a copy of your receipt or other proof of deposit from your financial institution Part 5: Financial Institution Name of Institution: Address: Escrow Acct. No. Total Amount Held: UNLESS PREVIOUSLY SUBMITTED, PLEASE SUBMIT A COPY OF ANY CONTRACT OR AGREEMENT WITH THE FINANCIAL INSTITUTION ESTABLISHING AND SHOWING ALL TERMS OF THE ESCROW FUND. _____________________________________________________________________________________________ Part 6: Signature Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this affidavit is true and accurate. This document must also be signed and dated by an authorized notary public. Title: Name of Authorized Agent: Signature of Authorized Agent: Date: Subscribed and sworn to before me on this date: Signature of Notary Public: City or County of My Commission expires: American LegalNet, Inc. www.FormsWorkFlow.com Mail this affidavit to: Office of the Attorney General Consumer Protection and Antitrust Bureau 33 Capitol Street Concord, NH 03301 Attn: Marie M. Labrie Copies may be e-mailed to Marie.Labrie@doj.nh.gov . However, you must still mail a signed original. Form: www.doj.nh.gov/consumer/tobacco/manufacturers.html American LegalNet, Inc. www.FormsWorkFlow.com Consumer Protection and Antitrust Bureau Office of the Attorney General 33 Capitol Street Concord, NH 03301 SCHEDULE A Non-Participating Manufacturer Reporting Form Please provide the following information with respect to cigarettes sold to purchasers within the State of New Hampshire. Add additional Pages if necessary. Company Name: ___________________________________________________________ Reporting Year: 2011 Brand Name (a) No. of Cigarettes Sold in New Hampshire (b) Signed under the Pains and Penalties of Perjury Dated: ___________________________________ Ounces of Roll-YourOwn Tobacco Sold in New Hampshire (c) Name & Address of the Wholesaler, Distributor or Retailer to Whom Each Cigarette Was Sold (d) Name & Address of the First Importer of Foreign Manufactured Cigarettes (e) Name and Title: _____________________________________________________ Email Address: _____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com