Declaration of Tobacco Product Importer Accepting Joint and Several Liability with Non-Participating Manufacturer for Escrow Compliance in Oklahoma And Appointing Resident Agent for Service of Process (OAG-TOB4-2009) This Declaration must be executed by an officer of the Importer with authority to bind the Importer to the requirements of Oklahoma law as stated below. Execution of this declaration is an assertion that all information provided is true and correct, and that the Importer accepts and agrees to all the terms specified below. 1. Tobacco Product Importer Identification Company’s Full Legal Name: _____________________________________________________ G Type of Business Entity (check one): G Sole Proprietorship G General Partnership G Limited Partnership G Corporation G Limited Liability Company G Other (specify): ____________________________________________________________ State/Country where Created, Incorporated or Registered: ______________________________ Include with declaration: • A copy of the current Articles of Incorporation, Certificate of Limited Partnership, Articles of Organization, or comparable applicable document, including any amendments, must be attached to the declaration. • A copy of the Importer’s current Tobacco Importer’s Permit issued by the United States Alcohol and Tobacco Trade Bureau, with any amendments. Trading As (list all names ever used):______________________________________________ Federal Employers Identification Number:___________________________________________ Federal Tobacco Importer Permit Number:___________________________________________ Physical Address: _____________________________________________________________ Mailing Address: ______________________________________________________________ Company Phone: ______________________________________________________________ Contact: _____________________________________________________________________ Title: ________________________________________________________________________ Phone: ___________________________ Fax:_______________________________________ Email: ____________________________ Website: ___________________________________ Name, Title and Dates of Service for all Current and Past Officers, Directors and/or Partners: ____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com If the Tobacco Product Importer is represented by outside counsel for the purpose of compliance with 68 O..S. §360.5-1, provide the following information: Firm:________________________________________________________________________ Attorney: _____________________________________________________________________ Address: _____________________________________________________________________ Phone:__________________________________Fax:_________________________________ Email:________________________________________________________________________ 2. Importing Contract Information The Importer identified above imports into the United States cigarettes manufactured by: Tobacco Product Manufacturer’s Name: ____________________________________________ _____________________________________________________________________________ The cigarette brands imported by the Importer for the Manufacturer identified above are as follows: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ The Importer imports these cigarettes under: (Check one): G Written contract commencing ____________________ and expiring ___________________. G Oral contract or informal agreement. 3. Acceptance of joint and several liability: In accordance with 68 O..S. §360.5-1of the Oklahoma statutes for all sales of the brands of cigarettes identified above which occur in Oklahoma, the Importer hereby accepts joint and several liability with the Tobacco Product Manufacturer identified above for deposit of all escrow due, payment of all penalties imposed and all costs and attorneys fees imposed in accordance with Sections 600.21 through 600.23 of Title 37 of the Oklahoma Statutes. This liability shall apply to all such sales in Oklahoma commencing January 1, 2010, and continuing until ninety days after written revocation of this acceptance is received in the Oklahoma Attorney General’s Office. 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. Appointment of resident agent for service of process in Oklahoma: In accordance with 68 O.S. §360.4 and 68 O.S. §360.5 of the Oklahoma Statutes, the Importer hereby appoints the resident agent in the State of Oklahoma identified below as its agent for the service of process on whom all process, and any action or proceeding against it concerning or arising out of the enforcement of Title 37 O.S. §600.21 through 600.23 may be served in any manner authorized by law: Agent: ______________________________________________________________________ Company: ___________________________________________________________________ Address: ____________________________________________________________________ Phone: ______________________________ Fax: ___________________________________ Email: ______________________________________________________________________ A current statement from the registered agent certifying service in this capacity must be attached to the declaration. 5. Execution of Declaration: I hereby affirm that all the information stated in this declaration is true and correct, and I hereby commit the Importer identified above to all the terms of this declaration. _________________________________ (Signature of Declarant) _________________________________ (Printed Full Name of Declarant) _________________________________ (Title of Declarant as Officer of Importer) Notary: City/County of________________________ , State of ________________________________ Subscribed and Affirmed before me on this date: _____________________________________ Signature: ___________________________ Printed Name: ___________________________ Notary Public My commission expires:________________. Mail this original fully executed Declaration, including attachments and supporting documents to: Tobacco Enforcement Unit Office of the Attorney General of Oklahoma 313 NE 21st Street Oklahoma City, Oklahoma 73105 3 American LegalNet, Inc. www.FormsWorkFlow.com