NPM-US State of New Jersey Certification of Brand Family and Units Sold Certifcation Part 1: Certification Year and Type of CertitìcaiIon Ye:ir: Complete a separate f0l11 for each certification year for which you arcccrtífying. Ccriilìcaiion year 201 I is for sales made in 2010. (check one) o Type ofCertification: (check one) Initial o o o o 2011 Annual Other: Supplemental Company Name Mailing Address City St~l!c Zip Code Phone Fax Web Address COUI1UY Name and Title or Person Completing this Fonn Part 3: Brand Family Certification (Attach Brands Addendum pages as necessary) The undersigned manufacturer certifies, under penalty of perjury, as of the date oftliis CCl1ifícatiol1, it is a Non-Participating Manufacturer (NPM) and is in full compliance with NJ.S.A. 52:4Dø 1£1.2.. The undersigned NPM certifies that the following list is a complete list or all of its brand families which are to be deemed to be its cigarettes (including RYO product) for purposes ofNJ.S.A. 52AD-J£1..§. Nothing in this certification shall limit or otherwise affect the State's right to maintain that a brand family constitutes cigarettes or roll-your-own tobacco of a different tobacco product manufacturer for purposes ofNJ.S.A. 52:4D-l£..~. Include with your certification sample packaging for each brand family named. If you have previouslv supplied packaging to the Attorney General, and if the packaging has not changed, samples need not be supplied with this certification. You must submit new packaging each time you change your packaging or add new brand familes. Rcpon Units Sold in Stick.~ for Cigareltes :md in Ounces for RYO Brand Family Check One Units Sold in 2009 Units Sold in 2010 Packaging Check Here if packaging was previously submitted and is unchanged, Flavoring Check Here if your cigarettcí RYO has a characterizing flavor other menthol, clove or tobacco, NJ,S,A, NJ,S,A.2A: 52:4D- i G.d. 170-51.6 o Cigarette o RYO o Cìg:m::ne o RYO o Cigarette o RYO o Cigarette o RYO o Cigarette o RYO o Cigarene o RYO Total of RYO Ounces Total of Cigarette Sticks American LegalNet, Inc. www.FormsWorkFlow.com New Jersey State of NPM-US Certification of Brand Family and Page 2 of 4 Units Sold Part 4: Certifcation of Escrow Acconnt and Agreement The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account, pursuant 10 N.JS'.A. 52:40-1 N. ff. Name of Financial Instítution (Escrow Agent) Mailing Address City Slate Phone Fax Contact Person Contact E~Maii Escrow Account Number Total amount held in this 3ccount for the Staii: orNew Jersey New Jersey Sub-Account Number s Arc funds held for the benefit of the State of l(yolJ answered "yes," write the (Ow,1 amount of Zip Code New Jersey in any account other than that listed above? all funds thai arc bcìng held in any account for the bcncÎli oCtlie Slale of Nc\v Jersey, ìncludìni. ¡he amOlllt lisled above. Has the Qualified Escrow Agreement been approved by the Attomey General? DYes Attach an executed copy of your current escrow agreement whether or not it has already been approved by the Attorney General. o No DYes o No s Dale of Agrccmeni; Approval Date: Part 5: Worksheet for Cigarettes Sold Dnring Liabilty Year Refer to \Vorkshcet at left to calculate the number of individual cigarettes bearing New Jersey cigarette tax stamps, including roll- Total ofRYO Ounces from Part) your-own tobacco (.09 ounces = 1 cigarette), which were manufactured by this manufacturer and sold in New Jersey during R YO Stìck Calculation (Divide this reporting period. RYO Ounces by .09) Certifcation Year 2011 \Vorksheet is for sales made in 2010: o Total of Cigarette Stick.. from Part) Total NPM Sales o Other: Please convert pounds to ounces before using this \\'orksheet. (Multiply by 16 for each pound.) (Add RYO $tìck Calculation to Total of Cigar 2011 cue Sticks) Part 6: Deposit Amonnt Use the rdtes listed below to figure the appropriate deposit amount. For the liabilty year 2010 the rate pcr cigarette is . . . ....... .....................$ 0.0188482 For the 201 0 liability period, the int1ation adjustment pcrcelHage is.. . .. ........m..... 45.55773% SO.OI 88482 x OA555i73 "" Escrow amount owed per stick, adjusted for ínl1atíon. Collact the New Jersey Offiæ oftJie Attorney Generalfor rates for prei'ioiisyears. Enter the escrow amount owed per siick, adjusted by iní1atioii. 2 Wrile the amount ofToial NP~-I Sales C;¡Jculaied in Part 5 of this worksheet. 2 S 0.0274350 3 fI.1ultiply Linc i by Line 2 and wrìtc down this number. This is the total amount to be paid into the escro\v account 3 for this ¡¡ability year by the m:muf;ictuler identifed in Part 2 of this \vorksheeL 4 Enter the total ¡imOllnl paid into ¡he escrow account for this Iiabìlty year. 4 S 5 Amount over/under-paid (DifTerence between Line 4 and Line 3.) Provide explanation if not zero. 5 S Note: Attach a copy of your receipt or other proof of deposit fi'om your financial institution. American LegalNet, Inc. www.FormsWorkFlow.com State of NPM-US New Jersey Certification of Brand Family and U nits Sold Part 7: Certifcation of Deposits, Withdrawals and Transfers Page 3 of 4 Attach separate page for each siib~account. TI1C NPM ccltifics thc following to be a complete record of each deposit and withdrawal or transfer which has occulTed from any and all accounts containing funds held for the benefit of the State of New Jersey. Report ending balances of all such accounts, even where no dcposÎts or withdrawals occurred. Attach copies ofrccords of the financial institution documenting any account activity. New Jersey Sub-Account Number Name of Financial Institution (Escrow Agent) Withdrawal or Transfer Amount Deposit Amount Date Explanation for \Vìthdrawal or Tr.msfer . Column Totals S Ending Balance for this New Jersey Sub-Account WithdrawalslTransfers Deposits S S American LegalNet, Inc. www.FormsWorkFlow.com NPM-US New Jersey State of Certiication of Brand Family and Page 4 of 4 Units Sold Part 8: Designated Contact Company Name Name Title ¡".1aiiing Address City State Zip Code Phone Fax E~Ma¡i I Couniry Part 9: Mannfaeturer Certifcation perjury, I state that, to the best of my knowledge, all of the infoniiaiion contained in this Certification and any aiiachcd documents arc true and accurate and thai I am a person authorized to bind the manufacturer making ihis certification ciihcr _under the Jaws of the State of New Jersey or ofilicjurisdiciion where the manufacturer resides or is organized. I understand thaI the Attorney General may require additional infomiaiioii and/or Under penalties of documentation to determine whether the manufacturer qualifi¡;'S for listing on the New Jersey Directory. 11iis dociimem must he .'giied and dated by UJI authorized !Jotary public. NPM Authorized Designee (Prim Name) Title Signature ofNPM Authorized Designee Dale Subscribed and s\voii 10 before me this date: Signature or Natary Public County Commission Expires Checklist of required documeuts o NPM-US CcrtiJication of Brand Family and Uniis Sold o Sample packaging for each brand family identified in Part 3 (unless previously supplied and it has not changed) o NPM-A Certification of Appoìntl1cni of Agent for Service of Process and auachmenis o Proof of Deposit for Part 6 o NP1VI-AI Certìfication of Additional Infomiation o Bank records confirming deposits, withdrawals or transfers for Part 7 o NPM-S NOI1~Partìcipating Manufacturer's Sales hifomiatíon o Any Brands Addendum pages for Part 3 Brand Family o Qualified Escrow Agn'ciient (unless prevìously approved) Certification o Any Accounts Addendum pages for Part 7 Certification of Deposits, Withdrawals and Transfers Mail to For Additional Information Submit the completed certificaiìon and other required documentation to the Tobacco Enforcement aiihis address: Phone DAG Glenn T, Graham at 973-648-7457 New Jersey Attorney General's Oflce 124 Halsey Street p,O, Box 45029 Newark, New Jersey 07101 Attn: DAG Glenn T, Graham ûrvisit: http://www.nj.govíoagíoag._tobacco.htmI Rev. 2/10/2011 American LegalNet, Inc. www.FormsWorkFlow.com New Jersey State of NPM-US Certifcation of Brand Family and Instructions Units Sold General Information Where do I send my completed Certification'! Mail this completed Certification (NPM-US), the NPM-A fom1 Who must fie this Certification '! (Certification of Appointment of Agent for Service of Process), the Any Non~Pal1icìpatìrig Manufacturer whose cigarettes or roll-your- own tobacco (RYO) were sold in New Jersey during the preceding calendar year or who intend for their brands to be lisled as compliant in the New Jersey Attorney Generals Manufacturers Participating Manufacturer's Sales lnfonnaiion) and related documents to: NPM-AI (Certification of Additional Information), NPM-S (Non- Dìrectory_ If a brand is not listed in this certifcation, it wil not New Jersey Attorney General's Offce be listed in the Directory. Tobacco Enforcement What is a Non-Participating Mannfactnrer'! P.O, Box 45029 Newark, New Jcrsey 07101 124 Halsey Street A Non-Participating Manutàcturcr (NPM) is any cigarette (including RYO) manufacturer who has not signed on to the tobacco Master Settlement Agreement (MSA). Specific Instructions It is unlawful to stamp or offer for sale in the State of New .Jersey any cigarette or RYO brand which is not included in the Ncu' Jersey Attorney Generals Manufacturers Directory. NonParticipating Manufacturers wil receive written notification when their brands have been deemed compliant for sale in New Jersey. Part 1: Certifcation Year and Type of Certifcation Check appropriate certification year. Vou must submit a separdte certification for each year you are certifying. If What is a qualified escrow fund'! An escro\V arrangement with a U.S. federal or U.S. slale chartered IÌnancial institution having no affliation with any Tobacco Product Manufacturer and having assets of at least one bîlion dollars "Other" is checked, enter liability year for which cCI1ification is being provided. Check whether this is an initial (manufacturer is not currently listed 15, 2011 for 2010 on the New Jersey Directory), annual (due April sales) or supplemental (change of information provided to the Attol1ey General) certification. ($ I ,000,000,000) where such arrangement requires that the financial institution hold the escrowed funds' principal for the benefit of Releasing Parties and prohibits the Tobacco Product Manufacturer placing the funds into escrow from using, accessing or directing the use of the funds' principal except as consistent with the applicable NPM Statutes. Part 2: Mannfacturer Identification Provide your company name, address, phone, fax, web address, FEIN, and name and title of person completing the form. Part 3: Brand Family Certification A 11 funds shall be held by the Escrow Agent in sub~accounts separate and apart from al i other funds and sub~accounts of each Beneficiary State. Fabricator: Entity that assembles the tobacco product for consumer use, i.e., assembles tobacco into cigarettes or blends and packages tobacco into RYO tobacco. Brand Family: Provide the brand name, which may include many When mnst I make my escrow payment' brand styles (menthol, 100'5, etc.). You must deposit all escrow payments into your qualified escrow fund on or before April i 5 each year. A fter you have made your deposit, provide a copy of your receipt or other proof of deposit from your financial institution, along with your escrow agreement, any amendments and this certification. Identify each Brand Family of all cigarettes that the company intends to sell in New Jersey, either directly or indirectly through any distributor, wholesale dealer, retailer or similar intemiediary, and seeks to have included in the Directory. Flavoring: Identify RYO, cigarettes or a component part thereof that causes cigarettes or smoke from them to have a characterizing flavor other than menthol, clove or tobacco. ffmore than one company manufactures a brand you arc certifying (e.g., you manufacture only the RVO or only the menthol cigarettes, etc. for a given brand), provide a written explanation of which brand styles you manufacture. Identify the other manufacturer by name and address, and provide a list of brand styles they manufacture, if Updates required The NPM shall update its certification list at least 30 days prior to any addition to or modification of the NPM's brand families by executing and delivering a supplemental cenification to the Attorney General. When is this Certification due'! known. If the identity of the other manutàcturer is unknown, provide The annual Certification must be fied with the Attorney General no later than April i 5 of each year for the preceding year. An initìal certification may be fied at any time. the trademark owner for the brand. Only one company can certify for a brand family. Check whether the product is cigarettes or RYO. the name and address of Where a brand is offered as both cigarettes and RVO, make a separate entry for each. Units sold: List the total RYO ounces and total cigarette sticks separately for both the preceding calendar year and the current American LegalNet, Inc. www.FormsWorkFlow.com calendar .year (as of the date of certification). If you \vere not the manufacturer of a listed brand in the preceding year, identify by name and address the manufacturers of such Brand Families. Provide original packaging for one brand style which is representative of each brand family to be certified. Flat, empty cartons arc preferred. If you have previously supplied packaging to the Attoiiey General and if the packaging has not changed, samples need not be supplied with this certification. Place a check mark in the column provided for each brand family to which this applies. Submit new pack¡~ging each time you change Attach proof of deposit(s) from your financi~ii institution. Proof must include the account number of the New Jersey sub-account, the date of deposit, and the amount or deposit. Such proof can be submitted as a letter from the bank. Provide an explanation for any discrepancy between the amounts listed on Lines 3 and 4. Part 7: Certification of Deposits, Withdrawals, and Transfers Use a separate page for each account or sub-account in which funds the State of New Jersey. Identify the New Jersey sub-account number and escrow agent (financial institution). Provide dates and amounts of deposits, withdrawals, and transfers for all activity prior to the date of certification. For ANY withdrawal or transfer, you must provide a brief explanation. are held for the benefit of your packaging or add new brand families. The Attorney General may require a tobacco product manufacturer to submit any additional infonnation including, but not limited to, samples of the packaging or labeling of each brand family as is necessary to enable the Attorney General 10 detennine whether a tobacco product manufacturer is in compliance with N.J.S.A. 52:4D.I £.. §£. For initial cel1ification under NJ.S.A. 52:40- i £1. S£., provide all Part 4: Certification of Escrow Account and Agreement Identify the name, address, phone and fax number for the financial institution (escrow agent) where the NPM has established a qualified Escrow Fund pursuant to N.J.S.A. 52:4D-1 £1. ô£. Provide the name and e-mail address for a contact person at the deposit, withdrawal, or transfer activity (for each account) for the entire time each account has been funded. For any accounts where New Jersey funds are NOT held separate and apart from that of other states, all activity must be repolted, regardless of whether it involves funds held for the State of New Jersey. Provide records from the Financial Institution to document any account activity. financial institution. Escrow Account Number: Provide the account number for the main escrow account, if one exists. New Jersey Sub-Account Number: Provide the account number for the New Jersey sub-account to which a deposit or deposits have been made for the liability year identified in Part 5. Total amount held in this account for the State of New Jersey: Amount held in the New Jersey sub-account identified as of the date of certification. If there arc any other account~ held for the benefit of the State of New Jersey, provide the total amounts held in these accounts the date of (including the sub-account listed in Part 4) as of certification. If your escrow agreement has been approved by the Attomcy General under N.J.S.A. 52:4D-I £1. §£. check "Yes." Please provide the effective date of the Escrow Agreement as well as the date of approval by the Attorney General. If your escrow agreement has not been approved by the Attorney Part 8: Designated Contact Provide the name, title, address, phone and fax numbers, and e-mail address for the individual the Attorney General should contact with respect to matters relating to this CCl1ification. The designated contact is the individual who will receive Attorney General mailings, including the annual certification mailing. Part 9: Manufacturer Certification The authorized designee executing the certification must be an offcer, principal, director or other authorized representative ofihe manufacturer. The authorized designee's name and title must be legibly printed and the signature must be notarized. Rev. 2/10/2011 General under NJ.S.A. 52:4D~1 .£. §.. check "No" and allacli an executed copy. Part 5: Worksheet for Cigarettes Sold During Liabilty Y car Use the instructions in the worksheet to convert RYO product to sticks and combine it with the cigarette stick count for the liability yeaL The result of this calculation will be used to detcnnine the deposit amount in Part 6. Part 6: Deposit Amount Use Lìnes i through 3 to calculate the total amount to be paid into escrow for the liability year identified in Part 5. The amount listed on Line 4 should include the total orany quarterly, reconciliation, or other payments which have been made for the liability year identified in Part 5, as of the date of certifïcation. 111e amount listed on Line 5 is the difference, if any, between the amounts listed on Line 3 and Line 4. American LegalNet, Inc. www.FormsWorkFlow.com