NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER BRAND IDENTIFICATION FORM (Copy this form and attach for each additional brand) Pursuant to R.C. 1346.02 and 1346.05 and Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 The non-participating manufacturer identified in Part 1 of the Certificate of Compliance has the following brand, which the tobacco product manufacturer affirms is deemed its cigarette or RYO tobacco for purposes of R.C. 1346.02 and 1346.05. Please note that pursuant to R.C. 1346.05(A)(4)(b) the Attorney General retains the discretion to determine that the cigarettes or RYO tobacco in a brand family constitute the cigarettes of another tobacco product manufacturer. Complete for each brand sold in the 2011 calendar year and at any time in the current calendar year. 1. Non-Participating Manufacturer Name (Complete one form for each brand) 2. Brand Identification and Sales Information 2a. Brand Name: 2c. Total units of this brand sold in Ohio for 2011: ________________________________________ NOTE: .09 oz. of RYO constitutes one unit. 2b. Cigarettes or Roll-Your-Own (check one) ___ Cigarette ___ RYO 2d. Is this brand currently being sold in Ohio as of the date of this certification? ___ Yes ___ No 3. Is the factory address different than the manufacturer address listed in Part 1 of the Certificate of Compliance? Yes No If yes, complete 3a. through 3e. below. 3a. Factory Address: 3b. Factory Phone No.: 3d. Factory Fax No.: 3c. Factory Manager’s Name: 3e. Manager’s Phone No.: 4. If this brand was previously manufactured by another entity, provide the names and addresses of such manufacturers. 4a. Name of Previous Manufacturer: Address of Previous Manufacturer: 5. Federal Requirements (cigarettes only) For the brand family identified in Part 2a of this form, provide a copy of the current Federal Trade Commission (FTC) letter, authorizing this brand’s health-warning rotation plan. (for cigarettes only) 5b. FTC Expiration 5c. Health Warning Rotation Plan 5d. Relationship to Manufacturer: 5a. Date of FTC Date: Submitted to FTC by: Compliance letter: For the brand family identified in Part 2a of this form, provide a copy of the current Centers for Disease Control (CDC) letter, approving this brand’s ingredient listing. (for cigarettes only) 5f. CDC Expiration 5g. Ingredient Reporting Submitted to 5h. Relationship to Manufacturer: 5e. Date of CDC Date: CDC by: Compliance Letter: 6. Name, address and phone number of trademark owner(s): Any license agreement or other document providing permission to the Tobacco Product Manufacturer to use the trademark must be included. 6a. Name of trademark owner: 6b. Address of trademark owner: 6c. Registration and/or serial number of trademark: 7. Compliance with the Ohio State Fire Marshal’s Proof of “Reduced Ignition Propensity” Certification 7b. Date of Fire Marshal’s Approval 7a. Certification has been submitted to the Ohio Fire Marshal and is: ___ Currently Listed ___ Pending Approval 7b. Date Fire Safe Certification Expires: Form NPM002 (Rev. 03/2012) American LegalNet, Inc. www.FormsWorkFlow.com