TES 226 008 (2/19) Page 1 of 15 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 Number Fax Number 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 Manufacturer222s Federal Taxpayer ID# Name of Importer Importer222s Address Importer222s Federal Taxpayer ID# US Customs ID# Verify that all currently held information is correct and has not changed or expired. Yes No If 223No,224 please attach updated documentation and complete all sections of this form. PART II: First Quarter Certifications (unless there have been changes to previously submitted information or previously submitted documentation has expired) General Questions for the Manufacturer (attach additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com TES 226 008 (2/19) Page 2 of 15 Incomplete or illegible certifications will not be processed 1. Are you the actual manufacturer (i.e. fabricator) of the brands listed in this certification? Yes No If 223No,224 please explain your reason for certifying. 2. 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 rights 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 3. Attached a copy of the Federal Trade Commission (FTC) approval letter for the current year for all brands listed in this certification? Yes No If 223No,224 please explain why it is not available. 4. Attached 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 please explain why it is not available. 5. Have you ever had an enforcement action taken against you that you have not previously disclosed to this Office? Yes No If 223Yes,224 list the state(s) involved, date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously supplied information on these types of actions, please list year of disclosure. 6. 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 223Yes,224 list the state(s) involved, date and a detailed explanation. (Attach additional sheets if necessary.) If you have previously supplied information on these types of actions, please list year of disclosure. 7. Attached a copy of the PA Department of Revenue222s Cigarette Manufacturer Certificate for fire safe cigarettes and corresponding laboratory test results? Yes No N/A If 223No,224 please explain why it is not available. 8. Attached a copy of the Pennsylvania Tobacco Products License (RYO)? American LegalNet, Inc. www.FormsWorkFlow.com TES 226 008 (2/19) Page 3 of 15 Incomplete or illegible certifications will not be processed Yes No N/A If 223No,224 please explain why it is not available. 9. Is a copy of your current qualified escrow agreement on file with our office? Yes No If 223No,224 please attach a copy of a new qualified agreement which has been approved by this office. 10. Are any of your brand styles, contained in this certification, currently under review or been issued a Non-Substantial Equivalence Order or otherwise recalled by the FDA within the past two (2) years? Yes No If 223Yes224 provide the FDA documentation regarding the Non-Substantial Equivalence Order or recall for all 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 compliance with 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 all regulations promulgated thereunder, and therefore able to be sold legally in the United States. Should a brand style be determined to be Non-Substantially Equivalent or otherwise recalled by the FDA 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. 11. Have your manufacturing facilities changed locations within the last certification year? Yes No If 223Yes224 provide an address of this facility as well as photos and diagram of the manufacturing facility. 12. Is the responsible party current with your 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 247 375 226 378? For verification purposes, please provide all monthly Pact Act reports from the prior calendar year listing shipments of any of your tobacco products into Pennsylvania regardless of the entity who filed the Pact Act Reports. Yes No Verification will be made with the PA Department of Revenue. PART III: First, Second, Third and Fourth Quarter Brand Family Identification (attach additional sheets if necessary) Section A. Brands Currently Certified and on the Directory List brand styles that will remain on the Directory Brand Style/Flavor Filter/Non Package Cigarette/RYO American LegalNet, Inc. www.FormsWorkFlow.com TES 226 008 (2/19) Page 4 of 15 Incomplete or illegible certifications will not be processed Indicate with an asterisk(*) any brands previously sold that are not being sold in the current year. Section B. Brands to be Removed from the Directory List brand styles currently on the Directory that will no longer be certified. Brand Style/Flavor Filter/Non Package Cigarette/RYO Section C. Additional Brands to be Certified List additional brand styles to be added to the Directory. List the Brand and Stamping Agent. Brand Style/Flavor Filter/Non Package Cigarette/RYO Section D. Quarterly Shipment History Manufacturers filing quarterly must complete the following table with their prior quarter222s shipments. Include all shipments to Pennsylvania distributors (directly or indirectly), regardless of whether the tobacco products ultimately remained in Pennsylvania. Also, include shipments from licensed non-resident (out-of-state) distributors that shipped into Pennsylvania. List your brand families, distributors/CSAs and the number of sticks that were shipped into Pennsylvania last quarter. If you were not the sole manufacturer of a brand family, on a separate sheet provide the name and address of every other manufacturer and the dates of manufacture by each manufacturer. Brand Family225 PA Licensed Cigarette Stamping Agent/Distributors Number of Sticks/Ounces Shipped to each CSA Total Units Shipped 225Indicate with an asterisk (*) any brands previously shipped that are not being shipped in the current year. PART IV: First Quarter Certifications (unless there have been changes to previously submitted information or previously submitted documentation has expired) Residency Status The undersigned certifies that the above-named Tobacco Product Manufacturer (check one): American LegalNet, Inc. www.FormsWorkFlow.com TES 226 008 (2/19) Page 5 of 15 Incomplete or illegible certifications will not be processed is a resident of the Commonwealth of Pennsylvania has appointed the registered agent identified below for service of process in the Commonwealth of Pennsylvania Resident Agent/Company Name Date of Appointment Address CityState Zip Code Telephone Number Fax