Page 1 of 2 Form PM003 (Rev. 0/201) PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATION OF PACT ACT INFORMATION Pursuant to R.C. 1346.02 and 1346.05 And Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 Part 1: Sales Year and Type of Certification Sales Year for this Certification: Complete a separate form for each sales year for which you are certifying. (check one) 201 Other Type of Certification: (check one) Initial Annual Supplemental Part 2: Participating Manufacturer Identification Company Name: Part 3: PACT Act Registration 1 Has manufacturer registered as a tobacco manufacturer with the Ohio Department of Taxation? Yes No 2 Has importer registered as a tobacco manufacturer with the Ohio Department of Taxation? Yes No N/A 3 Provide the name and address of your Ohio registered agent: Name: Address: 4 Provide a listing of states with which manufacturer has registered as a tobacco manufacturer: Part 4: PACT Act Reports 1 Has manufacturer filed monthly reports of all shipments or transfers of cigarettes and tobacco products into Ohio during 201 and 201 with the Ohio Department of Taxation? Yes No 2 Has importer filed monthly reports of all shipments or transfers of cigarettes and tobacco products into Ohio during 201 and 201 with the Ohio Department of Taxation? Yes No N/A 3 Provide a list of states for which manufacturer has filed monthly reports of shipments or transfers of cigarettes and tobacco products in 201 and 201: N/A American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Form PM003 (Rev. 0/201) 4 Provide the mode of delivery, including the name and address of the person delivering the cigarettes or other tobacco products into Ohio and other states: Mode of Delivery Name Address Part 5: Miscellaneous Information 1 Provide a list of states into which manufacturer shipped or transferred cigarettes and tobacco products in 201: 2 Provide a list of the name and address of the importers, distributors, wholesalers or retailers to which manufacturer made direct shipments or transfers of cigarettes and tobacco products in 201: NameAddress 3 Provide a list of states in which manufacturer advertises or offers for sale cigarettes, RYO, or smokeless tobacco, even if no direct shipments or transfers were made into such states: American LegalNet, Inc. www.FormsWorkFlow.com