S TATE OF S OUTH C AROLINA NPM QUARTERLY SALES INFORMATION AND QUARTERLY ESCROW PAYMENT CERTIFICATION FORM 2018 Manufacturer Identification Company Name: Date: Address: City: State: Zip: Country: Telephone Number: Fax Number: E-Mail Address: Name/Title of Person Completing Form: Quarterly Report (check one ): 1st Quarter - Jan.-Mar. 2nd Quarter - Apr.-Jun. 3rd Quarter - Jul.-Sep. 4th Quarter - Oct.-Dec. Other: (First Quarter Escrow Deposit Due Apr. 30th / Form Due May 10th) (Second Quarter Escrow Deposit Due July 30th / Form Due Aug. 10th) (Third Quarter Escrow Deposit Due Oct. 30th / Form Due Nov. 10th) (Fourth Quarter Escrow Deposit Due Jan. 30th / Form Due Feb. 10th) Units Sold i n South Carolina in the Quarter (attach additional pages a s ne eded ) Instructions for Manufacturer: List each distributor that is responsible for South Carolina tax on the cigarette and RYO brand(s). For each distributor, provide the sales information requested. Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sol d to Distributor: (Sticks or RYO Ounces) Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold t o Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Fami ly: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Distributor Name: Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) Brand Family: Check One: RYO Cigarette Units Sold to Distributor: (Sticks or RYO Ounces) For Attorney General Use Only: Total Cigarette Sticks: Total RYO Ounces: Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Certification of Escrow Account and Agreement Name of Financial Institution (Escrow Agent): Mailing Address: City: State: Zip Code: Phone: Fa x: Contact Person: Contact Email: Escrow Account Number: Total amount held in account for state of South Carolina: South Carolina Sub - Account Number: Calculating the Escrow Deposit Amount for Sales in 2018 1a) Enter the total number of cigarettes sold in South Carolina in 2016 (0.09 ounces of "roll-your-own" tobacco shall constitute one individual "cigarette"): 1b) 2a) Escrow Rate for Units Sold in 2018*: 2b) X $0.0347539 3a) Multiply the amount in Box 1b by the escrow rate in box 2b and enter the product in box 3b: 3b) The amount in Box 3b is the amount that must be deposited into Escrow Account for this quarterly period. Please attach a copy of your receipt or other proof of deposit from your financial institution. *The minimum 2018 NPM escrow rate is $0.0347539 per/stick. This minimum rate is based on a minimum upward inflation adjustment of 3%. If the CPI-U increases by more than 3% in 2018, the 2018 NPM escrow rate will be greater than $0.0347539. Federal Excise Tax Paid Total nationwide sales on which federal excise tax was paid in this Quarter: Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com This Form Must Be Signed and Dated Before a Notary Public Execution By Authorized Designee By executing this document I confirm that I am a qualified company officer or designee authorized to bind the applicant company. Under penalty of perjury, I state that the information contained in this Certification is true and accurate. Company Officer / Designee Dated: , 201 8 Sworn to and subscribed before me on this day of , 2018. (Seal) Notary Public (Print Name) My commission expires: Please mail the completed form to: South Carolina Office of the Attorney General Tobacco Enforcement Unit P.O. Box 11549 Columbia, SC 29211 Please email a copy to: sctobacco@scag.gov Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com