Non-participating Tobacco Manufacturer’s Certificate of Compliance with Escrow Payment Requirement on Sales in Oklahoma in 2007 Line 1: Tobacco Manufacturer’s Identification Name: ______________________________________________________________________________ Address:______________________________________________________________________________ _____________________________________________________________________________________ Phone: _______________________________________________FAX___________________________ Email: ______________________________________________________________________________ Brand Name(s) Manufactured: ____________________________________________________________ _____________________________________________________________________________________ (Styles such as Regular, Menthol, Light, etc., may be omitted only if all are made by the same Manufacturer) Location of Manufacturing Facility(s):______________________________________________________ Line 2: Units Sold in Oklahoma in 2007 Number of individual cigarettes and “roll-your-own” tobacco (.09 ounces of roll-your-own tobacco is counted as a cigarette) sold in Oklahoma by the Manufacturer—whether sold directly or through a distributor, retailer or similar intermediary or intermediaries:____________________________________________________ Line 3: Base Escrow Amount The Base Escrow amount is determined by multiplying the number of units sold, from Line 2, by $0.0188482. Base Escrow Amount $________________________________ Line 4: Inflation Adjustment The Inflation Adjustment is determined by multiplying the Base Escrow Amount, from Line 3, by 33.20594% (or, $0.0062587 per unit). American LegalNet, Inc. www.FormsWorkflow.com Inflation Adjustment Line 5: Total Escrow Payment Due The Total Escrow Payment Due is determined by adding the Base Escrow Amount, from Line 3, to the Inflation Adjustment, from Line 4 (or, $0.0251069 per unit sold). $________________________________ Total Escrow Payment Due $________________________________ Attach a copy of your executed Escrow Agreement and for all deposits attach copies of your receipt or other proof of deposit from the financial institution. Line 6: Amount Deposited in Escrow Account Total Amount Deposited in the Escrow Account for the State of Oklahoma based on sales in Oklahoma in 2007 (should be an amount not less than the amount of the Total Escrow Payment Due, from Line 5): Amount Deposited in Escrow Account $________________________________ Line 7: Financial Institution Name of Institution: _________________________________________________________________ Address: __________________________________________________________________ Escrow Acct No: __________________________________________________________________ Phone No.: _________________________________ Email: ____________________________________ Line 8: Signature Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certificate of Compliance is true and correct. This Certificate of Compliance must also be signed and dated by an authorized notary public. Name of Authorized Agent: _________________________________ Title: ____________________ Signature of Authorized Agent: _________________________________ Date: ____________________ Subscribed and sworn to before me on this date:______________________________________________ Signature of Notary Public: ______________________________ City or County of __________________ My Commission expires: _____________________________ [S E A L ] This Certificate of Compliance together with a copy of your signed Escrow Agreement and Proof of Deposit must be received at the address below by April 30, 2008. Office of the Attorney General State of Oklahoma Tobacco Enforcement Unit 313 NE 21st Street Oklahoma City, Oklahoma 73105 2 American LegalNet, Inc. www.FormsWorkflow.com