STATE OF NORTH CAROLINA TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE [Pursuant to N.C. Gen. Stat. 24766-291 and 24766-294] 2019 NON-PARTICIPATING MANUFACTURER222S APPLICATION/ANNUAL CERTIFICATION FORM NOTICES THE SALES YEAR FOR WHICH YOU ARE CERTIFYING COMPLIANCE IS 2018. FILING DEADLINE is April 30, 2019. Certification Forms must be postmarked no later than April 30, 2019 to avoid removal from the North Carolina Tobacco Directory. Please Type or Print. The Attorney General222s Office will not process incomplete or illegible Certification Forms.An application will be deemed incomplete if the applicant(s) is/are under a NC Revenue Suspension, the applicant(s) certificate of authority to transact business is revoked, or the applicant(s) fail(s) to obtain a certificate of authority from the NC Secretary of State when required by law. This Certification Form must be supplemented to reflect any change in information at any time during the year. Any change of information must be submitted 30 days prior to change. The failure to notify the Attorney General222s Office of any changes to this information 30 days prior to any change, including changes in address, may result in removal from the North Carolina Tobacco Directory. The denial of a certification, removal of the Applicant or its brands from any other state222s tobacco directory, or failure to notify the North Carolina Attorney General222s Office of same, may, in the Attorney General222s sole discretion, result in denial of this certification or immediate removal from the North Carolina Tobacco Directory. ESCROW DEPOSIT DUE DATES: April 15, 2019 is the escrow deposit due date for Nonparticipating Manufacturers (NPMs) subject to Annual Escrow Deposits. April 30, 2019 is the First Quarter Due date for NPMs subject to Quarterly Escrow Deposits. Please refer any questions to the Office of the Attorney General Tobacco Unit at (919) 716-6900. Mail this completed Certificate of Compliance and attachments to: NC Office of the Attorney General Special Litigation Section, Tobacco Unit P.O. Box 629 Raleigh, NC 27602 Please direct Hand Deliveries to the addressee at 114 W. Edenton Street, Raleigh, NC, 27603. Type of Certification (check one): Initial Certification 226 Applicant is not currently listed on the North Carolina Tobacco Directory Annual Certification 226 Due April 30, 2019 Supplemental Certification 226 Change of information provided to the Attorney General or request to add (or delete) brands to the North Carolina Tobacco Directory American LegalNet, Inc. www.FormsWorkFlow.com SectionA226Page1of11SECTION A: TOBACCO PRODUCT MANUFACTURER CERTIFICATION APPLICATION INSTRUCTIONS: NORTH CAROLINA REQUIRES THE ENTITY OR ENTITIES THAT CONTROL OR OWN THE MANUFACTURING PROCESS AND THAT CONTROL THE BRAND MARK, AS WELL AS THE IMPORTER, TO APPLY AND BE RESPONSIBLE FOR THE BRAND(S) APPROVED FOR SALE AND FOR THE RELATED ESCROW DEPOSITS. THIS FORM CONTAINS SECTIONS A, B, AND C. YOU MUST COMPLETE EVERY SECTION FOR EACH ENTITY REQUESTING TO CERTIFY A BRAND. SECTION A MUST BE COMPLETED BY THE TOBACCO PRODUCT MANUFACTURER. PLEASE SEE SECTIONS B AND C FOR FURTHER INSTRUCTIONS FOR COMPLETING THE FORM AS TO AN IMPORTER OR TRADEMARK OWNER. Part 1: Applicant Identification Information Tobacco Product Manufacturer (TPM) 1. Provide the Following Identification Information: Company Name: Mailing Address: Street Address (if different from mailing address): Name of person completing the application: Name of contact person (if different from above): Telephone Number: Fax No: Email Address: 2. As of the date of this application, the company identified above is (check all applicable boxes): Fabricator of Tobacco Product: Applicant is the manufacturer (i.e. fabricator) of the brands listed in this certification, which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. If you checked the above box: (a) attach photographs of your manufacturing facility including interior and exterior views and indicate on the photographs where the equipment and facilities for manufacturing (i.e. fabricating) the cigarettes, if any, are located; (b) provide the physical address for the manufacturing facility; and (c) provide proof of ownership, possession and control of the manufacturing facilities and equipment identified herein. Copy of Requested Documents Attached? Yes No First Importer for Resale in the United States If you checked the above box: (a) attach documentation identifying each cigarette manufacturer (i.e. fabricator), its plant address, mailing address, contact person, phone, and fax numbers and the relationship to the Applicant; and (b) identify the location of the transfer of ownership of cigarettes and a copy of every agreement or contract between the Applicant and fabricator. Attach additional sheets as necessary to provide a complete response. Copy of Requested Documents and Information Attached? Yes No American LegalNet, Inc. www.FormsWorkFlow.com SectionA226Page2of11 Trademark Owner of Brand Mark for brands listed in this certification. Note: If the Trademark Owner is an entity different from the TPM and has signed a Multi-Entity Escrow Agreement, then the Trademark Owner must complete 223SECTION C: TRADEMARK OWNER224 of this Certification Application. Other (Explain the relationship and attach additional documentation as necessary to provide a complete response.) 3. Is the Applicant the successor of a manufacturer or first importer? Yes No If 223yes,224 identify the predecessor(s) and attach additional sheets as necessary to provide a complete response. Additional sheets attached? Yes No 4. License and Permit Information (check all applicable boxes and provide corresponding information): ATF (TTB) Tobacco Permit TTB Permit Number: Expiration Date: N.C. Distributor222s License Number: If located in the U.S., Manufacturer222s Federal Taxpayer ID Number: 5. Copy of Applicable Permit(s) or License(s) Attached? Yes No 6. Does an entity, other than the TPM, import the Brand(s) listed in this certification? Yes No 7. If 223yes,224 provide copies of all contracts with the Importer(s) of the Brand(s). Response Provided Does Not Apply 8. Are you represented by an Attorney? Yes No 9. If Yes, then provide the Attorney222s Name, Firm Name, and Mailing Address: Attorney222s Telephone Number: Attorney222s Fax No.: Attorney222s Email Address: Part 2: Registered Agent Information N.C. Gen. Stat. 247 66-294(b)(1) requires an NPM to appoint and continuously maintain a process service agent within North Carolina to accept service of any notification or enforcement of an action under this Article. The NPM must file a certified copy of each instrument appointing a process service agent with the Secretary of State and the Office of the Attorney General. 1. TPM Registered Agent Information: Name of Registered Agent and Mailing Address: Name of Contact: Telephone: Fax: Email: American LegalNet, Inc. www.FormsWorkFlow.com SectionA226Page3of112. Has the Applicant attached an original letter from the Registered Agent accepting Appointment as Registered Agent on the company222s letterhead and dated for the current year? The Registered Agent must provide 30 Day notice prior to resignation. Yes No 3. Has the Applicant filed an instrument appointing a process service agent with the N.C. Secretary of State222s Office and attached a copy of that filing to this application? Yes No 4. Is the process service agent identified in the letter for above item 2 the same process service agent as the one in the instrument on file with the N.C. Secretary of State222s Office? If not, the applicant must update the filing with the N.C. Secretary of State222s Office. Yes No Part 3 TPM222s Organizational Information and Documents Identify your business structure by checking the applicable box: Individual or Sole Proprietorship Partnership Corporation Limited Liability Company Association Other (describe/explain): Check One: Response Does Not Provided Apply Attach the following documents or information: 1. Documents Filed with a Government Agency: Copy of document(s) regarding the for