TES -005 (2/19)Page 1of 12Incomplete orillegible certifications will not be processedComplete all fields or indicate N/A 226Do 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 CityStateZip CodeCountry Telephone NumberFax Number Factory Address (use additional sheets if necessary) Name of Designated Contact Name of Legal Counsel for cc (optional) Email AddressDesignated to Accept All Official CommunicationLegal Counsel Email Address Company Website Address Manufacturer222s Federal Taxpayer ID# Name of Importer Importer222s Address Importer222s Federal Taxpayer ID# US Customs ID# This Form is (check one):Annual Certification (due between April 15 and April 30 for Pennsylvania sales in the previous year)Supplemental Certification (changes to information on previously submitted forms)Initial Certification (Manufacturer not currently listed on Pennsylvania222s directory)Initial Certifications will require additional documentation. American LegalNet, Inc. www.FormsWorkFlow.com TES -005 (2/19)Page 2of 12Incomplete orillegible certifications will not be processed PART II: General Questions for the Manufacturer (attach additional sheets if necessary) 1. Are you the actual manufacturer (i.e. fabricator) of the brands listed in this certification? Yes No If 223No224 explain your reason for certifying. 2. If you have an MSA Amendment, are you still in compliance with the provisions of that Amendment? (Do not check N/A if you have an MSA Amendment.) Yes No N/A If 223No 224 explain. 3. Have there been any changes to your MSA Amendment within the last certification year? Yes No N/A If 223Yes224 provide an updated MSA amendment and explain the recent change. 4 . Are you the Trademark Owner of the brands listed in this certification? Yes If 223Yes224 attach a copy of your live trademark from the USPTO website. No If 223No224 provide the name and contact information of the owner , attach a copy of the live trademark from the USPTO website and a copy of any agreement that defines trademark right s and/or control over the manufacturing of the cigarettes (such as an exclusive manufacturing agreement) and attach an executed copy of such agreement. Live Trademark Attached Executed Agreement Attached 5 . Have you included a copy of the Federal Trade Commission (FTC) approval letter for the current year for all brands listed in this certification? Yes No If 223No224 explain why it is not available. 6 . Have you included a copy of the U.S. Centers for Disease Control (CDC) ingredient listing compliance letter for the current year for all of the brands listed in this certification? Yes No N/A If 223No 224 explain why it is not available. 7 . Have you ever had an enforcement action taken against you that you have not previously disclosed to this Office? Yes No If 223Yes224 list the state(s) involved , date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously suppliedon these types of actions,please list year of disclosure. American LegalNet, Inc. www.FormsWorkFlow.com TES -005 (2/19)Page 3of 12Incomplete orillegible certifications will not be processed 8 . Have you ever been denied Directory Listing in any other state or commonwealth that you have not previously disclosed to this Office? Yes No If 223Yes224 list the state(s) involved , date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously suppliedon these types of actions,please list year of disclosure. 9 . Attached a copy of the PA Department of Revenue222s Cigarette Manufacturer Certi ficate for fire safe cigarettesand corresponding laboratory test results? Yes No N/A If 223No224 explain why it is not available. 10 . Attached a copy of the Pennsylvania Tobacco Products License ( RYO ) ? Yes No N/A If 223No224 explain why it is not available. 11 . Is the responsible party current with their monthly report filings to the PA Department of Revenue in accordance with the federal Prevent All Cigarette Trafficking Act/Jenkins Act 15 U.S.C 247 375 226378? Yes No Verification will be made with the PA Department of Revenue. If 223No224 explain why they are not current . 12 . Are any of your brand styles , contained in this certification, currently under review or been issued a Non-Substantial Equivalence Orderby the FDA within the past two (2) years? Yes No If 223Yes224 provide the FDA documentation regarding the review/ recall of the brand or brand style and a detailed explanation.If 223No224 provide the completed notarized affidavit located at the end of this form stating all certifying brands/styles are current and in compliancewith FDA rules and regulations. For any newly added brand style(s) please provide documentation to establish the style(s) in compliance with the Family Smoking Prevention and Tobacco Control Act, and therefore able to be sold legally in the United States. Should a brand style be determined to be Non-Substantially Equivalent throughout the course of the year, you are required to provide information as soon as it is made available to ensure that products on the Directory remain legal for sale. 13 . Have your manufacturing facilities c hanged locations within the last certification year? Yes No If 223Yes224 provide an address of this facility as well as photos and a diagram of the manufacturing facility. American LegalNet, Inc. www.FormsWorkFlow.com TES -005 (2/19)Page 4of 12Incomplete orillegible certifications will not be processedINITIAL CERTIFICATIONS ONLY (Annual Certifications check N/A) 1. Have you attached p hotograph s and a diagram of the manufacturing facility? Yes No N/A If 223No 224 explain why it is not available. 2. Have you attached a copy of the company222s organizational chart? Yes No N/A If 223No 224 explain why it is not available. List all officers /owners of the applicant. Attach additional sheets if necessary. Name & Title Address Telephone Number Email Address 3 . Do you have any parent , subsidiar y sister or other affiliated entities ? Yes No If 223Yes224 list all such entities, their relationship and whether they m anufacture, sell or distribute tobacco products for sale in PA. Attach additional sheets if necessary. Company Name and Address Contact Person and Telephone Number Does this Company Sell or Distribute Tobacco Products forSale in PA American LegalNet, Inc. www.FormsWorkFlow.com TES -005 (2/19)Page 5of 12Incomplete orillegible certifications will not be processedPART III:Brand and StyleIdentification (attach additional sheets if necessary)Provide an electronic color copyof every brand style or promotional packaging. Include views of each side of the packagingwith UPC clearly visible.Section A.Brands Currently Certified and on the Directory(required on Annual Certifications only)List brands and stylesthat will remain on the Directory. Brand Style /Flavor Filter/Non Package Cigarette/RYO Indicate with an asterisk(*) any brands previously sold that are not being sold in the current year. Section B.Brands and Styles to be Removed from the DirectoryList brandsand stylescurrently on the Directory that will no longer be certified. Brand Style /Flavor Filter/Non Package Cigarette/RYO Section C.Additional Brandsand Stylesto be CertifiedList additional brandsand styles to be addedto the Directory. List the brand and Stamping Agent. If a brand family has been manufactured by more than one manufacturer, on a separate sheet of paper provide the name and address of every other tobacco product manufacturer and the dates the brand was producedby each manufacturer. Brand Style /Flavor Filter/Non Package Cigarette/RYO Brand Cigarette/RYO PA Licensed Cigarette Stamping Agent/Distributor PART IV:Execution by Corporate Officer or DirectorI 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 ofApproved Brands.I agree that al