ANNUAL ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Non-Participating Manufacturer) Part 1: Sales Year SALES YEAR: *If your company is required to make quarterly escrow deposits, you must complete the Quarterly Escrow Compliance Certificate and Affidavit. Part 2: Manufacturer Identification Name: Mailing Address: City: Physical Address: City: Phone: State: Zip: State: Fax: Country: Zip: Country: Email: Part 3: Units Sold Number of units of individual cigarettes and roll-your-own (RYO) tobacco sold in Oregon by the Manufacturer identified above during the sales reporting period is as follows: Total Number Units of Cigarettes Total Ounces of Roll-Your-Own (RYO) Total Number of Units of RYO (One unit = .09 ounces of RYO) TOTAL NUMBER OF ALL UNITS Non-Participating Manufacturer Brand Information: (Please add additional sheets if necessary. Brand Name (Omit styles such as Regular, Menthol, Light, etc. Cigarettes (C) or RYO (RYO) Annual Escrow Compliance Certificate and Affidavit Number of Units Sold During the Reporting Period Page 1 of 2 1141652-v2 American LegalNet, Inc. www.FormsWorkflow.com Part 4: Calculation of Deposit Amount For the sales reporting period: 2003 – 2006 – The rate per cigarette is …………………….. 2007 and thereafter – The rate per cigarette is …………. 0.0167539 0.0188482 A. The appropriate rate for the reporting period is: . . . . . B. Deposit Subtotal (Multiply total number of all units in Part 3 by the appropriate cigarette rate in Part 4 above) . . . . . . C. The Inflation Adjustment (Refer to www.doj.state.or.us Multiply Line B – Deposit Subtotal by the applicable inflation adjustment percentage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D. Total Escrow Deposit (Add Line B – Deposit Subtotal and Line C – Inflation Adjustment) ...................... Part 5: Financial Institution Name of Institution: Authorized Contact Name and Title: Phone: Fax: Email: Address: Escrow Account No: Sub-Account No: Total Funds Held in a Separate Account for Oregon: $ Date of Escrow Agreement: Date of Last Amendment to Escrow Agreement: (if applicable) Attached is a copy of the financial institution’s receipt or other proof of deposit of the proper escrow payment. Part 6: Signature Under penalty of perjury, I declare that I am authorized to certify on behalf of the Tobacco Product Manufacturer in Part 1 that all of the information contained in this Escrow Compliance Certificate, including but not limited to the attachments herewith, are true, complete and accurate. This Escrow Compliance Certificate must also be signed and dated by an authorized notary public. Name of Authorized Agent: Signature of Authorized Agent: Subscribed and sworn to before me on this date: Signature of Notary Public: My Commission Expires: Mail the completed original Escrow Compliance Certificate Affidavit with attachments to: Title: Date: County of: SEAL: Office of the Attorney General for the State of Oregon Oregon Department of Justice Civil Enforcement Division; Attn: Tobacco Enforcement 1162 Court Street, NE Salem, OR 97301-4096 Phone: (503) 934-4400 Fax: (503) 373-7067 Annual Escrow Compliance Certificate and Affidavit Page 2 of 2 1141652-v2 American LegalNet, Inc. www.FormsWorkflow.com