STATE OF OHIO TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE Pursuant to Ohio Revised Code §1346.02 and §1346.05 and Ohio Administrative Codes 109:8-1-01 thru 109:8-1-03 Mail this completed Certificate of Compliance and attachments to: Ohio Attorney General's Office Tobacco Enforcement Section - 4130 30 East Broad Street, 16th Floor Columbus, Ohio 43215 PART 1: A. TOBACCO PRODUCT MANUFACTURER IDENTIFICATION Complete company information below (please type or print): Company Name Address P.O. Box City/State/Zip/Country Telephone Number: Fax Number E-Mail Address Website URL Name/Title of Person Completing Form B. The tobacco product manufacturer identified above, as of the date of this Certification, is (check one below): A participating manufacturer [Complete Parts 1, 2, 4 and 8] A non-participating manufacturer [Complete entire form except Part 2] C. This form is (check one below): Initial Certification – Manufacturer is not currently listed on the Ohio Tobacco Directory. Annual Certification - Due April 30, 2007 for Ohio sales in 2006 Supplemental Certification – Change of information provided to the Attorney General. PART 2: PARTICIPATING MANUFACTURER’S BRAND FAMILY IDENTIFICATION (ATTACH ADDITIONAL SHEETS IF NECESSARY) The participating manufacturer identified in Part 1 has the brand families listed on pages 2 or 3 of this form and any attached addendum, each of which the manufacturer hereby affirms are to be deemed its cigarettes for the purposes of calculating its payments under the Master Settlement Agreement, in the volume and shares determined pursuant to the Master Settlement Agreement. Please note that pursuant to Ohio Revised Code '1346.05 (A)(4)(b) the Attorney General retains the discretion to determine that the cigarettes in a brand family constitute the cigarettes of another tobacco product manufacturer. NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com PARTICIPATING MANUFACTURER’S BRAND FAMILY IDENTIFICATION Indicate with an asterisk (*) those brands not being sold in current year. Attach addendum if necessary Brand Family Name Cigarette or RYO Manufacturing Factory Information if Different Than Named In Part 1 Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Brand Family Name Cigarette or RYO Manufacturing Factory Information if Different Than Named In Part 1 Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: Factory Phone Number: Factory Fax Number: RYO Factory Address: Cigarette Factory Phone Number: Factory Fax Number: Factory Manager’s Name: Manager’s Phone Number: Factory Phone Number: Factory Fax Number: RYO NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com PART 3: NON-PARTICIPATING MANUFACTURERS BRAND FAMILY IDENTIFICATION The non-participating manufacturer identified in Part 1 has the following brand families, each of which the tobacco product manufacturer affirms are to be deemed its cigarettes for purposes of ORC §§1346.02 and 1346.05. Please note that pursuant to Ohio Revised Code ' 1346.05 (A)(4)(b) the Attorney General retains the discretion to determine that the cigarettes in a brand family constitute the cigarettes of another tobacco product manufacturer. A. B. C. D. List all brand families sold in the 2006 calendar year and at any time in the current calendar year. Indicate by an asterisk (*) any brand no longer being sold in Ohio as of the date of this certification. .09 oz. of RYO constitutes one unit. Please include factory information if different than listed in Part 1. Attach additional sheets if necessary. Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Cigarette RYO Factory Address: Units sold in Ohio for 2006: Factory Manager’s Name: Manager’s Phone No.: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Units sold in Ohio for 2006: Cigarette RYO Factory Manager’s Name: Manager’s Phone No.: Factory Address: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) Brand Family Name: Cigarettes or Roll-Your-Own Cigarette RYO Factory Address: Units sold in Ohio for 2006: Factory Manager’s Name: Manager’s Phone No.: Factory Phone No.: Factory Fax No.: Previous Manufacturer (Name & Address) NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 5 of 10 American LegalNet, Inc. www.FormsWorkFlow.com PART 4: ADDITIONAL INFORMATION REQUIRED BY THE ATTORNEY GENERAL’S OFFICE A. A copy of the current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or importer as required by 26 U.S.C. §5712 and §5713 must be provided for the tobacco product manufacturer identified in Part 1A of this form. B. Name, address and Phone Number of the Trademark owner and any license agreement or other document providing permission to the Tobacco Product Manufacturer identified in Part 1A to use the trademark for each of the brand families certified in Part 2 or 3 of this form. C. For each brand family (cigarettes only) certified in Part 2 or 3 of this form, provide the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act (15 U.S.C. §1335a) and attach copies of all certificates of compliance. D. For each brand family (cigarettes only) certified in Part 2 or 3 of this form provide a copy of the current FTC rotation plan approval letter and the name and address of the entity that filed the health warning rotation plan with the FTC. E. For each brand family certified in Part 2 or 3 of this form, provide original packaging for one brand style which is representative of each brand family. Flat empty cartons are preferred. Submit new packaging each time you change your packaging or add new brand families. PART 5: NON-PARTICIPATING STAMPING AGENT or RYO DISTRIBUTOR AS IDENTIFIED IN ORC § 1346.04 List below the names and addresses of distributors selling manufacturer’s product(s) into Ohio to which the non-participating manufacturers identified in Part 1 has sold and intends to sell cigarettes and/or RYO tobacco. Attach additional sheet if necessary. Distributor Name Distributor Address Phone No. Brand NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 6 of 10 American LegalNet, Inc. www.FormsWorkFlow.com PART 6: NON-PARTICIPATING MANUFACTURER REGISTERED AGENT Check one below: The non-participating manufacturer identified in Part 1 is registered to do business in Ohio. The non-participating manufacturer identified in Part 1 has appointed and continues to engage the following agent located in Ohio. A current (dated this year) letter from the registered agent accepting this appointment must be attached. Name of Registered Agent Address City/State/Zip Telephone Number: PART 7: A. Fax Number NON-PARTICIPATING MANUFACTURER QUALIFIED ESCROW ACCOUNT Escrow Account Information The non-participating manufacturer identified in Part 1 has established and continues to maintain the following qualified escrow fund under ORC 1346.02. Name of Financial Institution Address City/StateZip/Country Contact Name/Title Telephone Number: Fax Number Escrow Account Number Ohio Sub-Account Number Provide name of any security interest in escrow account B. The Financial Institution noted in Part 7A of this certification, is required to provide the following: I. An executed copy of the Non-Participating Manufacturer’s current Escrow Agreement, along with any amendments or attachments. II. Proof of amount and date of deposit to Ohio’s segregated sub-account for 2006 sales. III. Current account ledger of the tobacco product manufacturer’s segregated sub-account for Ohio. IV. Provide name of any security interest in escrow account. NOTE: The above listed items are part of the Certification and must be sent to the Ohio Attorney General's Office directly from the named financial institution. These items are due by April 30, 2007. NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 7 of 10 American LegalNet, Inc. www.FormsWorkFlow.com C. Escrow calculation and deposit for sales in Ohio in 2006. 1. Show on Line A, the total units sold by non-participating manufacturer in Ohio during calendar year 2006: 2. On Line B, the applicable rate per unit sold in 2006 is the base rate per unit sold, $0.0167539, plus the inflation adjustment of $0.0046882 per unit. 3. Multiply Line A and B to determine the escrow deposit for 2006 sales in Ohio: A. (units) B. $0.0214421 C. (multiply A x B) DEPOSIT TO OHIO SEGREGATED SUB-ACCOUNT MUST BE MADE BY APRIL 16, 2007 D. Escrow Deposits Previously Made for 2006 Sales. Date of Deposit Amount of Deposit 1st Quarter Deposit 2nd Quarter Deposit 3rd Quarter Deposit 4th Quarter Deposit Annual Deposit E. Escrow Deposit/Withdrawal History for the State of Ohio (attach additional sheets if necessary): Withdrawals must comply with ORC § 1346.02 and verification of compliance must be provided. Date Deposit Total: Withdrawal Total: Balance Total: Send completed Certificate of Compliance and attachments to: Ohio Attorney General's Office Tobacco Enforcement Section - 4130 30 East Broad Street, 16th Floor Columbus, Ohio 43215 NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 8 of 10 American LegalNet, Inc. www.FormsWorkFlow.com PART 8: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER An authorized officer of the tobacco product manufacturer MUST sign this form and check one box below. This form MUST be notarized. This certification must be signed by a qualified company officer authorized to bind the applicant company. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand that the Attorney General may require additional information and/or documentation to determine if applicant and/or brands qualify for listing on the Ohio Directory. I have examined this certification, including attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct, and complete. On behalf of the Applicant the undersigned agrees that any action or proceeding against it arising from enforcement of the provisions of Ohio Revised Code §1346.01 through §1346.10 and any rules promulgated pursuant to these statutes, may be commenced against Applicant in any state court within Ohio, that the laws of the State of Ohio will govern such proceedings, and that Applicant waives any immunity from suit, liability, judgment and collection that Applicant may possess. Participating Manufacturer: Under penalty of falsification, I state that the tobacco product manufacturer named in Part 1 A, as of the date of this certification, is a participating manufacturer in full compliance with all applicable sections of Chapter 1346 of the Ohio Revised Code, and with the MSA amendment and or agreement applicable to its admission into the MSA. Non-Participating Manufacturer: Under penalty of falsification, I state that the tobacco product manufacturer named in Part 1A, as of the date of the certification, is a non-participating manufacturer in full compliance of all applicable sections of Chapter 1346 of the Ohio Revised Code. By signing this affidavit on behalf of the applicant company I understand that the company is required to comply with state and federal laws concerning the sale of tobacco products. __________________________________________________________________________________ Name of Officer of Tobacco Product Manufacturer (print name) Title __________________________________________________________________________________ Signature of Officer Date Subscribed and sworn to this date:_______________________________________________________ County of: _________________________________________________________________________ Signature of Notary Public: ____________________________________________________________ Notary Commission expires: ____________________________________________________________ NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. Page 9 of 10 American LegalNet, Inc. www.FormsWorkFlow.com CHECK LIST FOR COMPLETING CERTIFICATE OF COMPLIANCE FORM Pursuant to ORC § 1346.07 (C), the attorney general may require a tobacco product manufacturer to submit any additional information necessary to enable the attorney general to determine whether a manufacturer is in compliance with Sections 1346.05 to 1346.10. A. Participating Manufacturers Checklist Parts 1, 2, 4 and 6 must is completed in their entirety; Brand families have been listed and “Cigarettes” or “RYO” are checked; Brands that are not being sold in the current year have been marked with an asterisk (*); Copy of TTB permit enclosed; Name, address and phone number of trademark owner(s) enclosed; Copy of CDC compliance letter(s) enclosed; Copy of FTC approval letter(s) enclosed; Package samples enclosed: Certificate of Compliance is signed by an authorized officer of the tobacco product manufacturer; and Certificate of Compliance is notarized. B. Non-Participating Manufacturers Checklist All parts of Certificate of Compliance are completed except, Part 2; If registered agent has been appointed, letter from agent accepting appointment is attached; Current escrow agreement and any attachments and amendments are attached; Proof of escrow deposit for previous year’s sales are attached; Current escrow account statement from financial institution for Ohio sub-account is attached; Copy of TTB permit enclosed; Name, address and phone number of trademark owner(s) enclosed; Copy of CDC compliance letter(s) enclosed; Copy of FTC approval letter(s) enclosed; Package samples enclosed: Certificate of Compliance is signed by an authorized officer of the non-participating manufacturer; and Certificate of Compliance is notarized. NOTE: Incomplete and/or illegible Certificate of Compliance forms and its attachments will be returned. NOTE: The Attorney General’s Office will not process incomplete or illegible certifications. 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