Certification Pursuant to NMSA 1978, Sections 6-4-14 to 6-4-24 (2003) State of New Mexico GENERAL INFORMATION Who is required to file this certification? Any tobacco product manufacturer that intends to sell cigarettes within the state of New Mexico, whether directly or through any distributor, retailer, or similar intermediary. This Certification is in addition to any Certificate of Compliance that may be required pursuant to NMSA 1978 § 6-4-13 (1999) Definitions: (a) "Brand Family" means all styles of Cigarettes sold under the same trade mark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, "menthol," "lights," "kings," and "100s," and includes any brand name (alone or in conjunction with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of product identification identical or similar to, or identifiable with, a previously known brand of Cigarettes. (b) "Cigarette" has the same meaning as in NMSA 1978, § 6-4-12(D). (c) "Directory" means the listing of all Tobacco Product Manufacturers that have provided current and accurate certifications conforming to the requirements of NMSA 1978, Sections 6-4-14 to 6-4-24 (2003) and all Brand Families that are listed in such certifications; except as provided by NMSA 1978, Sections 6-4-14 to 6-4-24 (2003). (d) "Master Settlement Agreement" has the same meaning as in NMSA 1978, § 6-4-12(E). (e) "Non-participating Manufacturer" means any Tobacco Product Manufacturer that is not a Participating Manufacturer. (f) "Participating Manufacturer" has the meaning given that term in Section II(jj) of the Master Settlement Agreement and all amendments thereto. (g) "Qualified Escrow Fund" has the same meaning as that term is defined in NMSA 1978, § 6-412(F). (h) "Distributor" means a person required to affix stamps on cigarette packages pursuant to NMSA 1978, § 7-12-5 or required to pay excise tax imposed on cigarettes pursuant NMSA 1978 § 7-12-A-3. "Distributor" does not include a retailer of cigarette packages upon which stamps were already affixed when the packages were received by that retailer. (i) "Tobacco Product Manufacturer" has the same meaning as that term is defined in NMSA 1978, § 6-4-12(I). This certificate of compliance must be received by the Office of the Attorney General on or before April 30th of the year following the sales year. American LegalNet, Inc. www.FormsWorkflow.com a) "Units Sold" has the same meaning as that term is defined in NMSA 1978, § 6-4-12(J). When is this certification due? SPECIFIC INSTRUCTIONS: Part 1: Manufacturer's Identification. Identify the name, address, telephone, fax number and electronic mail address. Part 2: Sales Year. Identify the sales year. Part 3: Brand Family Identification. Identify by Brand Family and Brand name all of the cigarettes that the Tobacco Product Manufacturer intends to sell in this State whether directly or through any distributor, retailer, or similar intermediary, and seeks to have included in the Directory. Only the brands identified may be included in the Directory. A Participating Manufacturer shall include a list of its Brand Families. The Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General. A Non-Participating Manufacturer shall include in its certification (i) a list of all of its Brand Families and the number of Units Sold for each Brand Family that were sold in the State during the preceding calendar year, (ii) a list of all of its Brand Families that have been sold in the State at any time during the current calendar year, (iii) indicating, by an asterisk, any Brand Family sold in the State during the preceding calendar year that is no longer being sold in the State as of the date of such certification, and (iv) identifying by name and address any other manufacturer of such Brand Families in the preceding or current calendar year. The Non-Participating Manufacturer shall update such list thirty calendar days prior to any addition to or modification of its Brand Families by executing and delivering a supplemental certification to the Attorney General. Part 4: Non-Participating Manufacturer Certification A. Verify that the Non-Participating Manufacturer is registered to do business in New Mexico or has appointed an agent for service of process in the State of New Mexico and provided notice thereof as required by NMSA 1978, Sections 6-4-14 to 6-4-24 (2003) B. Identify (i) the name, address and telephone number of the financial institution where the Non-Participating Manufacturer has established a Qualified Escrow Fund pursuant to NMSA 1978, § 6-413; (ii) the account number of such Qualified Escrow Fund and any subaccount number for New Mexico; C. Identify (i) the amount such Non-Participating Manufacturer placed in such fund for Cigarettes sold in the State during the preceding calendar year, the date and amount of each such deposit; and (ii) the amount and date of any withdrawal or transfer of funds American LegalNet, Inc. www.FormsWorkflow.com the Non-Participating Manufacturer made at any time from such fund or from any other Qualified Escrow Fund. Part 5: Execution by Authorized Designees. The person executing the Certification must be an authorized representative of the Tobacco Product Manufacturer identified in Part 1. The Designee's name and title must be printed and the Certification must be executed in the presence of an authorized notary. American LegalNet, Inc. www.FormsWorkflow.com Certification Pursuant to NMSA 1978, Sections 6-4-14 to 6-4-24 (2003) State of New Mexico Part 1: Tobacco Product Manufacturer Identification Company: Address: Address: Phone: FAX Email: Name/Title of Person Completing Report: The Tobacco Product Manufacturer identified above is, as of the date of this Certification: (Initial One) ________ A Participating Manufacturer under the Tobacco Master Settlement Agreement _________A Tobacco Product Manufacturer in full compliance with NMSA 1978, § 6-4-13 Part 2: Sales Year Year of Sales for this Certificate of Compliance is: (Complete a separate certification for each year of sales)__________________ Part 3: Brand Family Identification (Attach additional Sheets if Necessary) Participating Manufacturers complete A & B; Non-Participating Manufacturers complete A through E. A. Brand Family B. Brand Name C. Units Sold Preceding Yr. D. Units Sold Current Yr. E. Manufacturer Part 4: Non-Participating Manufacturer Certification A. Registered Agent / Approved Agent for service of process American LegalNet, Inc. www.FormsWorkflow.com Agent Name: Company: Address: Address: Phone: FAX Email: [Has the Agent for Service of Process been approved by the Attorney General? By Whom: Approval Date: B. Qualified Escrow Fund — Financial Institution Name of Institution: Address: Phone: Representative Name: Escrow Acct No: __________________________________State Account No.:__________________ Has the Qualified Escrow Agreement been approved by the Attorney General?_______________________ By Whom:____________________________________ Approval Date:___________________________ C. Escrow Deposit/Withdrawal History for New Mexico Date Deposit Withdrawal 1 Balance Part 5. Execution by Authorized Designee Under penalty of perjury, I state that the information contained in this Certification is true and accurate. Designee (Print Name): ______________________________________ __________________________________________________________ T: t i e l Signature of Designee: _______________________________________ 1 Withdrawals must comply with NMSA 1978, § 6-4-13. Verification of compliance must be provided. American LegalNet, Inc. www.FormsWorkflow.com _______________________________________________________________________ a: ______________________________________________________________________ Dt e Subscribed and sworn to before me on this date: Signature of Notary Public: ____________________________ City or County of ______________ My Commission expires: ______________________________ Mail the completed certificate of compliance to: Office of the Attorney General Attn: David K. Thomson Deputy Attorney General P. 0. Drawer 1508 Santa Fe, NM 87504-1508 Fax (505) 827-6036 Street Address for Overnight or hand delivery: c/o Claudia Ravanelli 408 Galisteo Santa Fe, NM 87504 American LegalNet, Inc. www.FormsWorkflow.com