CERTIFICATE OF COMPLIANCE 23506 (2-2017) NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER Non-Participating Manufacturer Escrow Payment Manufacturer's Identification Name Address Phone Fax Sales Year (separate certificate for each year) Units Sold Total number of individual cigarettes and "roll-your-own" tobacco sold by the Manufacturer identified above. Brand Name Brand Name Brand Name Number of Cigarettes Number of Cigarettes Number of Cigarettes Total Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Escrow Rates and Payments For the sales year: (Use and adjust the rates listed below to figure the appropriate total deposit 2000 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2001-2002 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2003-2006 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2007 and thereafter - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . amount) 0.0104712 0.0136125 0.0167539 0.0188482 Inflation Adjustment For payments due April 17, 2017, multiply the deposit subtotal by 73.80355% (.7380355) and enter result. Deposit Subtotal $ Escrow Deposit Paid The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for the sales year. (Add deposit subtotal and the inflation adjustment amount.) Deposit Paid $ Note: For the initial deposit, attach a copy of your executed escrow agreement and for all deposits attach copies of your receipt or other proof of deposit from your financial institution and copies, if any, of amendments to your escrow agreement. Financial Institution Name of Institution Address Escrow Acct. No. Sub-Acct. No. Total Amount Held for the State $ American LegalNet, Inc. www.FormsWorkFlow.com Signature Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this Certificate of Compliance is true and accurate. The Certificate of Compliance must also be signed and dated by an authorized notary public. Name of Authorized Agent Signature of Authorized Agent Signature of Notary Public My Commission Expires Title Date Subscribed and sworn to on this date Mail this Certificate of Compliance to: Office of State Tax Commissioner Tobacco Tax Section 600 E. Boulevard Ave. Dept. 127 Bismarck ND 58505-0599 American LegalNet, Inc. www.FormsWorkFlow.com