For Office Use Only: Date Received: ___________   STATE OF SOUTH CAROLINA TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE [Pursuant to S.C. Code Ann. §§11-47-10 to -30, and §§11-48-10 to -110] 2011 CERTIFICATION FORM   IMPORTANT NOTICES FILING DEADLINE is April 30, 2011. Certification Forms must be postmarked no later than April 30, 2011 to avoid removal from the South Carolina Tobacco Directory. Mail this completed Certificate of Compliance and attachments to: South Carolina Office Please Type or Print. The Attorney General’s Office will not process incomplete or of the Attorney illegible Certification Forms. General Tobacco Unit This Certification Form must be supplemented to reflect any change in information at any P.O. Box 11549 time during the year. Any change of information must be submitted 30 days prior to Columbia, SC 29211 change. Please refer any questions to the Office of the Attorney General Tobacco Unit at (803) 7343704. PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION A. This Certification Form is (check one below): Initial Certification – Applicant is not currently listed on the South Carolina Tobacco Directory Annual Certification - Due April 30, 2011 Supplemental Certification – Change of information provided to the Attorney General or request to add additional brands to the South Carolina Tobacco Directory B. The Applicant identified below sells cigarettes to consumers within the State (whether directly or through a distributor, retailer, or similar intermediary or intermediaries), is (check one below): A participating manufacturer [Complete Parts 1, 2, and 7] A non-participating manufacturer [Complete entire form except Part 2] Page 1 of 16 American LegalNet, Inc. www.FormsWorkFlow.com C. COMPANY INFORMATION: Company Name: Mailing Address: City/State/Zip/Country: Telephone Number: Fax Number: E-Mail Address: Website: Name/Title of Person Completing Form: Name of Contact Person (if different from above): Company President: E-Mail Address: Company Vice President: E-Mail Address: Company Secretary: E-Mail Address: Company Treasurer: E-Mail Address: Address of Manufacturing Plant(s): Name of Factory Manager(s): Phone Number of Factory Manager: Fax Number of Factory Manager: If located in U.S.: Manufacturer’s Federal Taxpayer ID number: If located in U.S.: TTB Tobacco Manufacturer Permit Number: If located outside the U.S., applicable government Permit Number: D. Expires: Expires: ATTORNEY: Attorney’s Name: Firm Name: Firm Mailing Address: Telephone Number: Fax Number: E-Mail Address: Website: Page 2 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 2: PARTICIPATING MANUFACTURERS A. The Applicant became a participating manufacturer, (as that term is defined in Section II(jj) of the Master Settlement Agreement) on the following date: B. BRAND FAMILY IDENTIFICATION The Participating Manufacturer identified in Part 1 has the following brand families, each of which the manufacturer hereby affirms are to be deemed its cigarettes for the purposes of calculating its payments under the Master Settlement Agreement, in the volume and shares determined pursuant to the Master Settlement Agreement. Indicate with an asterisk (*) those brands not being sold in current year. Please attach additional sheet(s), as necessary, to provide a complete response. Brand Family Name C. Cigarettes or RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Brand Family Name Cigarettes or RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO REQUIRED DOCUMENTATION IN SUPPORT OF CERTIFICATION FORM 1. For the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 Telephone for General Information Locator: 202-326-2222 http://www.ftc.gov 2. Provide a copy of the current Centers for Disease Control (CDC) ingredient-listing (cigarettes only) compliance letter(s) pertaining to the above brands of cigarettes and a statement from the manufacturer as to which ingredients for a particular brand were submitted for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov/netinfo.htm Page 3 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 3. For the above brand families, provide a copy of the current Fire Standards Compliant (FSC) Cigarettes compliance letter(s). Additional information can be obtained at: SC FSC PROGRAM Office of State Fire Marshal 141 Monticello Trail Columbia, SC 29203 Telephone: 803-896-9800 http://www.llr.state.sc.us/firemarshal.asp 4. Provide copies of documentation showing that the applicant is in full compliance with the Prevent All Cigarette Trafficking (PACT) Act (15 U.S.C. § 375, et seq. (2010)). This documentation MUST include a copy of the Prevent All Cigarette Trafficking (PACT) Act Registration Form (ATF 5070), and South Carolina equivalent. Additional information can be obtained at: Bureau of Alcohol, Tobacco, Firearms and Explosives Alcohol and Tobacco Diversion Division 99 New York Avenue, NE Mailstop 7S-233 Washington, DC 20226 USA Or via e-mail to: PACTActregistrationinbox@atf.gov See: http://www.atf.gov/alcohol-tobacco/ 5. Please respond to the following: U.S. Treasury, Tobacco Tax bureau (TTB) Permit Number was obtained as a manufacturer and/or as an importer. Manufacturer Importer Attach a copy of Applicant’s current permit as a manufacturer or importer pursuant to 26 U.S.C. Chapter 52, and regulations issued there under. D. AFFILIATES Pursuant to S.C. Code Ann. § 11-47-20(b), an Affiliate “means a person who directly or indirectly owns or controls, is owned or controlled by, or is under common ownership or control with, another person. Solely for purposes of this definition, the terms ‘owns’, ‘is owned’, and ‘ownership’ mean ownership of an equity interest, or the equivalent thereof, of ten percent or more, and the term ‘person’ means an individual, partnership, committee, association, corporation, or any other organizations or group of persons.” Please identify any Affiliate that also manufactures, imports, distributes, or sells the applicants brand of cigarettes (including roll-your-own tobacco) in South Carolina. List the type of business by writing “m” for manufacturer, “i” for importer, “d” for distributor, and “w” for wholesaler.) Attach additional documentation, as necessary, to provide a complete response. Page 4 of 16 American LegalNet, Inc. www.FormsWorkFlow.com Brand Family Name E. Affiliate Name Type of Business Affiliate Address ADDITIONAL REQUIRED INFORMATION Please certify the following: a. Applicant sold cigarettes in South Carolina in the preceding calendar year: Yes No b. Applicant is in full compliance with the Prevent All Cigarette Trafficking (PACT) Act (15 U.S.C. § 375, et seq. (2010): Yes No c. Applicant advertises or sells cigarettes via the internet or in catalogs and uses the mail or other delivery service to deliver cigarettes to South Carolina consumers: Yes No d. Applicant or one of its Brand Families listed in the Certification was previously denied listing on the directory or was removed from the Directory: Yes No e. Applicant is enjoined or banned from selling any cigarettes by court order, state or federal agency ruling or determination: Yes No f. A Brand Family currently or formerly sold by Applicant or Brand Family that applicant intends to sell is enjoined from sale by a state court, state agency, or a federal court: Yes No g. A state or federal court has entered a judgment finding that Applicant engaged in an unfair business practice or unfair competition relating to the sale of tobacco products: Yes No h. Applicant is selling only Fire Standards Compliant (FSC) cigarettes into South Carolina: Yes No i. Applicant is in compliance with the Federal Family Smoking Prevention and Tobacco Control Act (Public Law 111-31), including Section 907(a)(1)(A), which bans the sale of all flavored cigarettes: Yes No Page 5 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 3: NON-PARTICIPATING MANUFACTURERS A. TOBACCO PRODUCT MANUFACTURER 1. Applicant is the manufacturer (i.e. fabricator) of the brands listed in this Certification, which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. Yes No If the answer is “Yes,” please attach a photograph or diagram of your manufacturing facility and indicate on the photograph or diagram where the equipment and facilities for manufacturing (i.e. fabricating) the cigarettes, if any, are located. 2. Applicant is the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States. Yes No If the answer is “Yes,” identify each cigarette manufacturer (i.e., fabricator), its plant street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to Applicant. Identify the location of the transfer of ownership of cigarettes and a copy of every agreement or contract between Applicant and fabricator. Attach additional sheet(s), as necessary, to provide a complete response. 3. Applicant is a successor of an entity described in questions 1 or 2 above (i.e., manufacturer or first importer). Yes 4. No If Applicant answered “No” to questions 1,2, and 3 above, explain the basis for Applicant’s claim that it is a Tobacco Product Manufacturer (TPM) as defined under South Carolina Code Ann. §§11-47-10 to -30, and §§11-48-10 to –110. Please submit all documentation to support Applicant’s contention. Attach additional sheet(s), as necessary, to provide a complete response. Page 6 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 5. Licenses / Permits U.S. Treasury, Tobacco Tax bureau (TTB) Permit Number was obtained as a manufacturer and/or as an importer. Manufacturer Importer Attach a copy of Applicant’s current permit as a manufacturer or importer pursuant to 26 U.S.C. Chapter 52, and regulations issued there under. B. BRAND FAMILY IDENTIFICATION 1. The non-participating manufacturer identified in Part 1 has the following brand families, each of which the tobacco product manufacturer affirms are to be deemed its cigarettes for purposes of S.C. Code Ann. §§11-47-10, et seq. Please note the following instructions: a. Please list all brand families sold in the preceding calendar year. b. Indicate by an asterisk (*) any brand no longer being sold in South Carolina as of the date of this certification. c. Please be advised that 0.09 oz. of RYO constitutes one unit. d. Please attach additional sheet(s), as necessary, to provide a complete response. e. Provide a sample of the packaging of each brand family. Brand Family Name Cigarettes or Roll-Your-Own Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Units Sold in S.C. in 2010 Page 7 of 16 American LegalNet, Inc. www.FormsWorkFlow.com C. REQUIRED DOCUMENTATION IN SUPPORT OF CERTIFICATION FORM 1. For the above brand families (cigarettes only) provide a copy of the current Federal Trade Commission (FTC) approval letter for health-warning rotation plan. Additional information can be obtained at: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Locator: 202-326-2222 http://www.ftc.gov 2. Provide a copy of the current Centers for Disease Control (CDC) ingredient-listing (cigarettes only) compliance letter(s) pertaining to the above brands of cigarettes and a statement from the manufacturer as to which ingredients for a particular brand were submitted for each approval letter. Additional information can be obtained at: Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 http://www.cdc.gov/netinfo.htm 3. For the above brand families, provide a copy of the current Fire Standards Compliant (FSC) Cigarettes compliance letter(s) (cigarettes only). Additional information can be obtained at: SC FSC PROGRAM Office of State Fire Marshal 141 Monticello Trail Columbia, SC 29203 Telephone: 803-896-9800 http://www.llr.state.sc.us/firemarshal.asp 4. Provide copies of documentation showing that the applicant is in full compliance with the Prevent All Cigarette Trafficking (PACT) Act (15 U.S.C. § 375, et seq. (2010)). This documentation MUST include a copy of the Prevent All Cigarette Trafficking (PACT) Act Registration Form (ATF 5070), and South Carolina equivalent. Additional information can be obtained at: Bureau of Alcohol, Tobacco, Firearms and Explosives Alcohol and Tobacco Diversion Division 99 New York Avenue, NE Mailstop 7S-233 Washington, DC 20226 USA Or via e-mail to: PACTActregistrationinbox@atf.gov See: http://www.atf.gov/alcohol-tobacco/ Page 8 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 5. Proof of Trademark Ownership and compliance with Federal Trademark Laws: Adequate assurance that Applicant owns or has the right to use the Brand referenced above and is in compliance with all intellectual property law. Please provide a certified copy of the trademark. In addition to a certified copy of the trademark documentation, please provide the following information: Brand Name D. Trademark Owner/Contact Person Physical Address & Phone Number Fabricator AFFILIATES Pursuant to S.C. Code Ann. § 11-47-20(b), an Affiliate “means a person who directly or indirectly owns or controls, is owned or controlled by, or is under common ownership or control with, another person. Solely for purposes of this definition, the terms ‘owns’, ‘is owned’, and ‘ownership’ mean ownership of an equity interest, or the equivalent thereof, of ten percent or more, and the term ‘person’ means an individual, partnership, committee, association, corporation, or any other organizations or group of persons.” Please identify any Affiliate that also manufactures, imports, distributes, or sells the applicants brand of cigarettes (including roll-your-own tobacco) in South Carolina. List the type of business by writing “m” for manufacturer, “i” for importer, “d” for distributor, and “w” for wholesaler.) Attach additional documentation, as necessary, to provide a complete response. Brand Family Name Affiliate Name Type of Business Affiliate Address Page 9 of 16 American LegalNet, Inc. www.FormsWorkFlow.com E. ADDITIONAL REQUIRED INFORMATION Please certify the following: a. Applicant sold cigarettes in South Carolina in the preceding calendar year: Yes No b. Applicant is in full compliance with the Prevent All Cigarette Trafficking (PACT) Act (15 U.S.C. § 375, et seq. (2010)). Yes No c. Applicant advertises or sells cigarettes via the internet or in catalogs and uses the mail or other delivery service to deliver cigarettes to South Carolina consumers: Yes No d. Applicant or one of its Brand Families listed in the Certification was previously denied listing on the directory or was removed from the Directory: Yes No e. Applicant is enjoined or banned from selling any cigarettes by court order, state or federal agency ruling or determination: Yes No f. A Brand Family currently or formerly sold by Applicant or Brand Family that applicant intends to sell is enjoined from sale by a state court, state agency, or a federal court: Yes No g. A state or federal court has entered a judgment finding that Applicant engaged in an unfair business practice or unfair competition relating to the sale of tobacco products: Yes No h. Applicant is selling only Fire Standards Compliant (FSC) cigarettes into South Carolina. Yes No i. Applicant is in compliance with the Federal Family Smoking Prevention and Tobacco Control Act (Public Law 111-31), including Section 907(a)(1)(A), which bans the sale of all flavored cigarettes. Yes No F. MARKETING AND DISTRIBUTION INFORMATION 1. List all brands made by Applicant since 1999. Attach additional sheet(s), as necessary, to provide a complete response. BRAND FAMILY NAME DATE(S) MADE Page 10 of 16 American LegalNet, Inc. www.FormsWorkFlow.com 2. Have any of the brand families listed above been manufactured by a different Manufacturer at any time? Yes No If yes, please identify by name and address any other Manufacturer of the listed Brand families in any proceeding or current calendar year. Attach additional sheet(s), as necessary, to provide complete response. Manufacturer Name 3. Address Brand / Brand Family Name Year Distributors and Wholesalers For each brand that Applicant intends to sell, list the name and address of every South Carolina distributor or wholesaler who will handle the product (i.e. cigarettes and RYO tobacco). Please indicate by asterisk (*), which entity is responsible for paying state excise taxes on the product. Distributor’s Name Name of Contact Person Address Phone Number Units Sold Date of Shipment(s) Page 11 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 4: REGISTERED AGENT FOR THE NON-PARTICIPATING MANUFACTURER A. REGISTERED AGENT 1. Please indicate one of the following: The non-participating manufacturer identified in Part 1 is registered to do business in South Carolina. The non-participating manufacturer identified in Part 1 has appointed and continues to engage the following Registered Agent located in South Carolina. 2. Please provide the following information: Name of Registered Agent: Company Name: Full Address of Registered Agent: Telephone Number: Email Address: 3. Fax Number: Applicant MUST attach current year letter from the Registered Agent listed above accepting appointment as Registered Agent. Page 12 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 5: QUALIFIED ESCROW ACCOUNT FOR THE NON-PARTICIPATING MANUFACTURER A. QUALIFIED ESCROW ACCOUNT INFORMATION 1. Please indicate one of the following: The applicant has established and continues to maintain a qualified escrow fund under S.C. Code Ann. §11-47-30(b)(1). The applicant has not established a qualified escrow account. 2. Please provide the following information: Name of Financial Institution: Contact Name / Title: Full Address of Financial Institution: Telephone Number: Email Address: Escrow Account Number: 3. B. Fax Number: South Carolina Sub Account Number: Applicant MUST attach a copy of the current Escrow Account Agreement. Any amendments or attachment to such agreements MUST be provided. QUALIFIED ESCROW ACCOUNT HISTORY 1. Event Date Please provide the escrow deposit and withdrawal history for the Qualified Escrow Account established for units sold in South Carolina. Please be advised that withdrawals must comply with S.C. Code Ann. § 11-47-30. Deposit Withdrawal Balance Page 13 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 6: ESCROW DEPOSIT FOR 2010 SALES YEAR A. FUNDS DEPOSITED INTO A QUALIFIED ESCROW ACCOUNT FOR 2010 SALES YEAR 1. Pursuant to S.C. Code Ann. § 11-47-30(b)(1), an approved tobacco product manufacturer shall place into a qualified escrow fund by April 15, of the year following the year in question a certain amount adjusted for inflation. For Non-Participating Manufactures making escrow deposits on April 15, 2011, for their 2010 sales, the proper per/stick rate, adjusted by inflation, is $0.0274350. 2. Please indicate one of the following: The applicant has deposited funds into a qualified escrow account for units sold in South Carolina during calendar year 2010. The applicant did not have sales in South Carolina during calendar year 2010. 3. Please provide the following information: 1. Show on Line A, the total units sold by non-participating manufacturer in South Carolina during calendar year 2010. A. (Units Sold) 2. On Line B, the applicable rate per unit sold in 2010 is the base rate per unit sold, $.0188482, plus the inflation adjustment of $0.0274350 per unit. B. ($0.0274350) 3. Multiply Line A and B to determine the escrow deposit for 2010 sales in South Carolina. C. (multiply A x B) DEPOSIT TO SOUTH CAROLINA SEGREGATED SUB-ACCOUNT MUST BE MADE BY: APRIL 15, 2011 B. PROOF OF DEPOSIT 1. The Financial Institution noted in Part 5 of this certification is required to provide directly to the Tobacco Unit of the South Carolina Attorney General’s Office the following: I. II. 2. Proof of amount and date of deposit to South Carolina’s segregated sub-account for 2010 sales. Current account ledger of the tobacco product manufacturer’s segregated subaccount for South Carolina. NOTE: These items are part of the Certification and are due by April 30, 2010. Page 14 of 16 American LegalNet, Inc. www.FormsWorkFlow.com PART 7: AFFIDAVIT OF TOBACCO PRODUCT MANUFACTURER Participating Manufacturer. Under penalty of falsification, I state that the tobacco product manufacturer named herein, as of the date of this certification, is a Participating Manufacturer in full compliance with all applicable sections of Title 11, Chapter 47 of the South Carolina Code. I understand that this certification must be signed by a qualified company officer authorized to bind the applicant company. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand that the Attorney General may require additional information and/or documentation to determine if applicant qualifies for listing on the South Carolina Directory. I have examined this certification, including attachments and supporting documents and, to the best of my knowledge and belief, this Certification, including attachments and supporting documents, is true, correct, and complete. Non-Participating Manufacturer. Under penalty of falsification, I state that the tobacco product manufacturer named in Part 1A, as of the date of the certification, is a non-participating manufacturer in full compliance with all applicable sections of Title 11, Chapter 47 of the South Carolina Code. I understand that this certification must be signed by a qualified company officer authorized to bind the applicant company. My position with the company and my actual authority to certify on behalf of the applicant meets the foregoing requirements. I understand that the Attorney General may require additional information and/or documentation to determine if applicant qualifies for listing on the South Carolina Directory. I have examined this certification, including attachments and supporting documents and, to the best of my knowledge and belief, this certification, including attachments and supporting documents, is true, correct, and complete. I affirm that the Certifying Tobacco Product Manufacturer consents to being sued in South Carolina Court of Common Pleas for the purposes of the State of South Carolina enforcing any provisions of S.C. Code § 11-47-10, et seq. or S.C. Code § 11-48-10, et seq. I understand that it is the responsibility of all Tobacco Product Manufacturers to track and report sales of cigarette and RYO brands sold in South Carolina no later than twenty days after the end of each calendar quarter, and more frequently if so directed by the Attorney General. [Signature Block on Following Page] Page 15 of 16 American LegalNet, Inc. www.FormsWorkFlow.com By signing this affidavit on behalf of the applicant company, I understand that the company is required to comply with all state and federal laws concerning the sale of tobacco products. Name of Company Officer (print or type name) Title Signature of Company Officer Date Subscribed and Sworn this date: (Seal) Notary Public for the State of: Notary Commission Expires: Mail this completed Certificate of Compliance and attachments to: South Carolina Attorney General's Office Tobacco Unit P.O. Box 11549 Columbia, SC 29211 Page 16 of 16 American LegalNet, Inc. www.FormsWorkFlow.com