State of New Jersey NPM-AI Non-Participating Manufacturer Certification of Additional Information Certifcation Part 1: Certifcation Year and Type of Ccitificatioii Year: Complete a separate tann for each Ccitifìcation year that you arc cCl1ìfying. Certification year 2011 is for sales made in 20 I O. (check one) o Type of Certifcation: (check one) Initial o o 2011 Annual Part 2: Manufacturer Identification o o Other: Supplemental Company Name Person Completing ihis Form Name and Title of Mailing Address City I Zip Code I Slare Phone i Country I FEIN i Fax Part 3: NPM Status References to cigarettes (includes rolI-your-own tobacco) arc to the brand families certified on the NPM-Ar fonn submitted by the manufacturer identified in Part 2. o Yes w No o Yes o No NPM is the fabricator of the brand families listed on the NPM-AI fomi and imends for the cigarettes to be sold in the U.S., including cigarettes intended to be sold in the U.S. through an impaneL NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the U.S. Part 4: Additional Information Requested by Attorney General's Offce Q All NPMs must provide the information requested in this s('('tion. Provide a response to each question. All attachments must indicate the question to wlth.'f¡ it corresponds. 1. A listing ofal! company offcers and owners (all persons with an equity interest of 10% OJ' more in company). 2. A complete list of cigarcltcs (including roll~your~own tobacco "RYO") that NPM, ìis principals, subsidiaries, affliates, successors, members, offcers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and place of rnanufacture for those brands. List the cigarettes and RYO by brand name, brand family 3. A compleie list of and flavor (other than tobacco, menthol, clove). tobacco producis (e.g. cigars, pipe tobacco, sniokeless tobacco, etc.) that NPM and its principals, subsidiaries, afflíates, successors, members, offcers, owners and directors manufacture no matter where sold; tín1c periods for manufacturc orthose brands; and the place ormanufacture for those brands. 4. Provide names, addresses, telephonc numbers, and, ¡favailable, emaÍl addresses of NPM sells cigarenes to (including RYO) located in New Jersey or another State. all tax stamping agents (licensed or not) ihe 5. Provide names, addresses, telephone numbers and, ifavailable, email addresses orall the retailers, importers, distrìbutors, wholesalers or similar intermediaries the NPM sells cigarettes to (including RYO) located in New Jersey or another Slate. 6. Provide a list of States that have certified the NPM and the brand familìes certified in those States. If any State has refused to list or removed NPM tì'om a State's directory, identify the State(s). 7. List all ¡memet websites where NPM cigarettes or tobacco products are sold, even ifwithoui NPMs express authorization. Provide the name, address and telephone number of owner of the domain name of the website. Provide a separate listing for each brand of cìgarettes or tobacco products if necessary. American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey NPM-AI Non-Participating Manufacturer Certification of Additional Information Part 4 (continued) 8. IfNPM intends to sell or 311horizcs any other entity to sell any cÎgarettes or roii-your~own into New Jersey by mail order or through the internet, provide the internet website and!or identify publications. Attach a lener addressed to the Attorney General's offce staiing you sent rcpol1s or invoices to the New Jersey Division of Taxation to comply with the Jenkins Act the U.S. Code, Section 375 et seq.), as amended by the Prevent All Cigarette Trafficking (PACT) (Chapter lOA ofTitlc i 5 of Act, for sales in the last i 2 months. Attach copies orany agreements authorizing another to sell your brand families by mail order or through the Înternet. ~ NPMs located in foreign countrìes must provide the infonliutìon rcqucsicd in this section. Provide a response!ü each question or indicate NIt\ All aiiachments must indicate ¡he question 10 which it corresponds, I. Copy of the license, permit or other registration documents required by the country where the br;nd fiim¡lies certified in P:irt 3 ofNPM-Al nrc inanU(;lctured, 2. Name, address, phone number, and email address for all importers for the bmnd famìles certified in Part 3 ofihc NPM-Al ccrtificntion fomi. ~ Part 5: Manufacturer Certifcation Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents arc true and accurate and that I am a person authorized to bind the manufacturer making this certification either under the laws of the Slate of New Jersey or of the jurisdiction where the manufacturer resides or is organized. I understand that the Attorney General may require additional information and/or documentation to determine whether the manufacturer qualifies for listing 011 the New Jersey Directory. Tlis document must be signed and dated by aii authorized liota1'Y public. NPM Authorized Designee (Print Name) Title Signature of NPM Authorìzcd Designee Date Subscribed and sworn to before me this date: Signature of County Notary Public Commission Expires Rev,2/10/2011 American LegalNet, Inc. www.FormsWorkFlow.com