Non-participating Tobacco Manufacturer’s Certificate of Compliance with Quarterly Escrow Payment Requirement on Sales in Oklahoma in 2011 (OAG-TOB3-2011) 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 2011 G Quarter No. 1: Jan. 1, 2011 - March 31, 2011 G Quarter No. 2: April 1, 2011 - June 30, 2011 Line 3: G Quarter No. 3: July 1, 2011 - Sept. 30, 2011 G Quarter No. 4: Oct. 1, 2011 - Dec. 31, 2011 Units Sold in Oklahoma in 2011 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 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) The Inflation Adjustment is determined by multiplying the Base Escrow Amount, from Line 4, by 49.9244619% (or, $0.0094098543 per unit). American LegalNet, Inc. www.FormsWorkFlow.com $________________________________ 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, $0.0282581 per unit sold). $________________________________ Total Escrow Payment Due For all deposits attach copies of your receipt or other proof of deposit from the financial institution. 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 2011, 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 Institution: _________________________________________________________________ Address: __________________________________________________________________ Escrow Acct No: __________________________________________________________________ Phone No.: _________________________________ Email: ____________________________________ Line 9: Signature Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certificate of Quarterly 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. 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 ] 2 American LegalNet, Inc. www.FormsWorkFlow.com This Certificate of Compliance together with Proof of Deposit must be received at the address below by May 15, 2011, for Quarter No. 1, August 15, 2011, for Quarter No. 2, November 15, 2011, for Quarter No. 3, and, February 15, 2012, for Quarter No. 4. See OTC Rule 710:70-9-4. Office of the Attorney General State of Oklahoma Tobacco Enforcement Unit 313 N.E. 21St Street Oklahoma City, Oklahoma 73105 * Title 37 O.S. § 600.23(A)(2) requires payments to be “adjusted for inflation.” Title 37 O.S. 600.21(1) defines “adjusted for inflation” as “increased in accordance with the formula for inflation adjustment set forth in Exhibit C to the Master Settlement Agreement. Each year this formula increases 3% or the actual inflation rate, whichever is greater. Because the actual inflation rate cannot be determined until the end of 2011, tobacco product manufacturers required to make quarterly escrow payments will be required, in their quarterly escrow payments, to deposit an amount that has been cumulatively adjusted for inflation by 3%. When the inflation rate for 2011 has been determined, manufacturers will be advised and then have until April 15, 2012, to deposit any additional money, if necessary, to satisfy the actual inflation amount under the Act. The 2010 cumulative inflation rate, 45.55773%, increased by 3% is 49.9244619%. Multiplying the 2011 base escrow deposit amount $0.0188482, by the inflation rate, 49.9244619%, equals the cumulative inflation adjustment amount of $0.009409854%. Adding the base escrow deposit amount, $0.0188482, to the cumulative inflation adjustment amount, $0.009409854, equals $0.028258 per unit for 2011. 3 American LegalNet, Inc. www.FormsWorkFlow.com