TES 226 007 (02/19) Page 1 of 4 Incomplete or illegible certifications will not be processed Complete all fields or indicate N/A 226 Do not leave blanks. Please review all instructions for further information. Failure to provide all necessary information will result in the rejection of your certification. PART I: Tobacco Product Manufacturer Identification Company Name Address City State Zip Code Country Telephone Numbe r Fax Numbe r Factory Address (use additional sheets if necessary) Name of Designated Contact Name of Legal Counsel for cc (optional) Email Address Designated to Accept All Official Communication Legal Counsel Email Address Company Website Address Verify that all currently held information is correct and has not changed or expired. Yes No If 223No,224 please attach updated documentation. PART II: Brand Family Identification (attach additional sheets if necessary) Provide an electronic color copy of every brand style or promotional packaging that has changed. Include views of each side of the packaging with UPC clearly visible. Section A. Brands Currently Certified and on the Directory with packaging changes List brands and styles with packaging changes Brand Style Flavor Filter/NonPackage American LegalNet, Inc. www.FormsWorkFlow.com TES 226 007 (02/19) Page 2 of 4 Incomplete or illegible certifications will not be processed PART III: Execution by Corporate Officer or Director I understand that any violation of the requirements of the Tobacco Product Manufacturer Directory Act of the Tobacco Settlement Agreement Act of 2000 is a basis for removal of the manufacturer222s brand families from the Commonwealth222s Directory of Approved Brands. I agree that all packaging images submitted with this certification are free of proprietary and confidential information and may be publicly posted on the Pennsylvania Tobacco Product Directory website. I hereby certify and declare under penalty of perjury that all of the statements and information contained in the certification, including but not limited to any accompanying statements or attachments herewith, are true, correct and complete and that I am a person authorized to bind the Tobacco Product Manufacturer making this certification either under the laws of the Commonwealth of Pennsylvania or of the jurisdiction where the manufacturer resides or is organized. Signature of Officer or Director: Date: Print Name: Title: Required Checklist: Included electronic color copy of all packaging to be used in Pennsylvania during the certification year. Include views of each side of the packaging with UPC clearly visible. Please be sure the packaging provided is clear of any proprietary information as it will be displayed to the public on the Pennsylvania Tobacco Product Directory of Approved Brands. Attached any documentation that expired since your last certification (FTC, CDC, TTB, FSC, Trademark certificates, etc.) Completed this certification in its entirety or indicated N/A with signature of Officer or Director. Reviewed and complied with the attached instructions. American LegalNet, Inc. www.FormsWorkFlow.com TES 226 007 (02/19) Page 3 of 4 Incomplete or illegible certifications will not be processed INSTRUCTIONS This Certification must be completed in English. All attachments must include a certified English translation if the original document is in a different language. Fill out the certification form completely. Do not leave any fields blank. Attachments must clearly indicate the section to which it corresponds. In place of paper copies, we recommend that you send all attachments via electronic media (CD/DVD/USB Drive). Part I: Tobacco Product Manufacturer222s Identification Provide the company name and complete addresses. Provide the telephone number and fax number for the company official signing this certification. Provide an email address and designated contact to receive all official office communication from our Office. Identify the name and title of the person completing the certification form. If using an outside agency to complete this certification, please identify the name of that agency. Part II: Brand Family Identification Provide an electronic color copy of every brand style or promotional packaging being changed. Include views of each side of the packaging with the UPC code clearly visible. Each time you change your packaging; add new brand styles; or, create a special, limited edition package you must submit an electronic color copy. When in doubt about packaging submission, please contact our Office for clarification. Section A - Identify by brand and style all of the cigarettes that are included in the Pennsylvania directory with packaging being changed. Part III: Execution by Corporate Officer or Director The Tobacco Product Manufacturer must certify that it is a Manufacturer in full compliance with the Tobacco Settlement Agreement Act. The person executing the Tobacco Manufacturer Certification Form must be an authorized Officer or Director of the Tobacco Product Manufacturer. A power of attorney will not be accepted. The designee222s name and title must be printed and signed. Definitions: a)223Brand Family224 - All styles of cigarettes sold under the same trademark and differentiated from one another by means of additional modifiers or descriptors, including, but not limited to, 223menthol,224 223kings,224 and 223100s.224 The term includes any use of a brand name, alone or in conjunction with any other word, trademark, logo, symbol, motto, selling message, recognizable pattern of colors or any other indicia of any product identification identical or similar to or identifiable with a previously known brand of cigarettes. American LegalNet, Inc. www.FormsWorkFlow.com TES 226 007 (02/19) Page 4 of 4 Incomplete or illegible certifications will not be processed b)223Cigarette224 - Any product that contains nicotine, is intended to be burned or heated under ordinary conditions of use and consists of or contains any of the following: (1)Any roll of tobacco wrapped in paper, or in any substance not containing tobacco. (2)Tobacco, in any form, that is functional in the product, which, because of its appearance, the type of tobacco used in the filler or its packaging and labeling, is likely to be offered to or purchased by consumers as a cigarette. (3)Any roll of tobacco wrapped in any substance containing tobacco which, because of its appearance, the type of tobacco used in the filler or its packaging and labeling, is likely to be offered to or purchased by consumers as a cigarette described in paragraph (1). Frequently Asked Questions Who is required to file this Certification? Every Manufacturer that intends to sell cigarettes in the Commonwealth, whether directly or through any distributor, retailer, or similar intermediary that has made changes to its certified cigarette brand style packaging. How is this Certification used? The Office of Attorney General uses the information provided in the certification to identify cigarette brand families included in the directory published pursuant to section 301 of the Tobacco Product Manufacturer Directory Act (TPMDA), 35 P.S.247 5702.301. Who should sign the Certification? The certification must be reviewed and signed by a Director or Officer of the Tobacco Product Manufacturer (TPM) with the authority to bind the company. A Power of Attorney will not be accepted. When must packaging be submitted? A manufacturer is required to provide an electronic color copy of each brand style showing all sides of the packs when submitting a certification. Include views of each side of the packaging with UPC clearly visible. American LegalNet, Inc. www.FormsWorkFlow.com