STATE OF OKLAHOMA Non-Participating Tobacco Manufacturer’s Certificate of Compliance with Escrow Payment Requirement on Sales in 2011 Line 1: Tobacco Manufacturer’s Identification Name: ______________________________________________________________________________ Address:______________________________________________________________________________ _____________________________________________________________________________________ Phone: _______________________________________________ FAX: _________________________ Email: ______________________________________________________________________________ Brand Name(s) Manufactured: _____________________________ ______________________________ _____________________________________________________________________________________ (Styles may be omitted if all are made by the same Manufacturer) Location of Manufacturing Facility(s):______________________________________________________ Line 2: 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: ___________________________________________________ Units Sold in Oklahoma in 2011 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 49.92446% (or, $0.0094099 per unit). $________________________________ Inflation Adjustment Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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, $0.0282581 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 2011 (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: ______________________ STATE OF _______________ ) COUNTY OF _______________ ) ss. 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:___________________________________________ Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 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, 2012. Office of the Attorney General State of Oklahoma Tobacco Enforcement 313 NE 21st Street Oklahoma City, Oklahoma 73105 OAG-TOB2 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com