NON-PARTICIPATING TOBACCO MANUFACTURER'S CERTIFICATE OF COMPLIANCE WITH QUARTERLY ESCROW PAYMENT REQUIREMENT ON SALES IN 2019 Line 1: Tobacco Manufacturer's Identification Name: Address: Phone: Facsimile: Email: Brand Name(s) Manufactured: Location of Manufacturing Facility(s): Line 2: Quarter in 2019 Quarter No. Line 3: Units Sold in Oklahoma in this Quarter of 2019 Number of individual cigarettes and "roll-your-own" tobacco sold in Oklahoma by the Manufacturer whether sold directly or through a distributor, retailer or similar intermediary or intermediaries: Cigarettes Sold in Oklahoma in 2019: RYO (0.09 ounces of RYO tobacco is counted as 1 unit): Line 4: Base Escrow Amount The Base Escrow Amount is determined by multiplying the number of units sold, from Line 3, by $0.0188482. Base Escrow Amount: Line 5: Inflation Adjustment (Estimated) OKLAHOMA ATTORNEY GENERAL - TOBACCO ENFORCEMENT UNIT American LegalNet, Inc. www.FormsWorkFlow.com The Inflation Adjustment is determined by multiplying the Base Escrow Amount, from Line 4, by 89.91999% (or, $0.0169483 per unit). Inflation Adjustment: Line 6: Total Escrow Payment Due The Total Escrow Payment Due is determined by adding the Base Escrow Amount, from Line 4, to the Inflation Adjustment, from Line 5 (or, $0.0357965 per unit sold). Total Escrow Payment Due: Line 7: Amount Deposited in Escrow Account Total Amount Deposited in the Escrow Account for the State of Oklahoma based on sales in Oklahoma in 2019, Quarter No. , (should be an amount not less than the amount of the Total Escrow Payment Due, from Line 6). Amount Deposited in Escrow Account: Line 8: Financial Institution Name of Financial Institution: Address: Escrow Account No.: Phone No.: Email: Please mail escrow deposit confirmation documents to: Office of the Oklahoma Attorney General Tobacco Enforcement Unit 313 N.E. 21st Street Oklahoma City, Oklahoma 73105 American LegalNet, Inc. www.FormsWorkFlow.com Line 9: Signature This Certificate of Compliance must also be signed and dated by an authorized Notary Public. Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Quarterly Certificate of Compliance is true and correct, and that I am an officer authorized to legally bind the above-named company either under the laws of the State of Oklahoma or of the jurisdiction where the manufacturer resides or is organized. Name of Authorized Agent: Title: Signature of Authorized Agent: Date: STATE OF ) COUNTY OF ) COUNTRY OF ) On , 20 , before me personally appeared , personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the instrument herein and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Signature: My Commission expires: My Commission Number: This notarized Certificate of Compliance, together with Proof of Deposit, must be received at the address below by April 30, 2019 for Quarter No. 1; July 31, 2019 for Quarter No. 2; October 31, 2019 for Quarter No. 3; and January 31, 2020 for Quarter No. 4. OTC Rule 710:70-9-4. Office of the Oklahoma Attorney General Tobacco Enforcement Unit 313 N.E. 21st Street Oklahoma City, OK 73105 You must sign and mail the original form to the address above. American LegalNet, Inc. www.FormsWorkFlow.com