SOUTH DAKOTA Certificate of Compliance Non-Participating Manufacturer Escrow Payment South Dakota Codified Law Ch. 10-50B 201Sales Reporting Period: Quarter 4 Plus Outstanding 201 Inflation Adj. Deposit Due: April 15, 201 Part 1: Manufacturer's Identification Name: Address: Phone: Fax: List of Brand families: "Brand families" is defined as: all styles of cigarettes and roll your own tobacco sold under the same trademark and differentiated from one another by means of additional modifiers or descriptors, and any 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 product identification identical, similar to, or identifiable with a previously known brand of cigarettes or roll your own tobacco. Part 2: Units Sold Number of individual cigarettes and "roll-your-own" tobacco units (0.09 oz = 1 unit) sold by the Manufacturer identified above during Quarter 4 of : The calendar year is divided into the following quarters: January 1st to March 31st (Quarter 1); April 1st to June 30th (Quarter 2); July 1st to September 30th (Quarter 3); and October 1st to December 31st (Quarter 4). Part 3: Escrow Rates and Payments For the sales year , the rate per cigarette is . . . . . . . . $0.0188482 Part 4: Escrow Deposit Due Without Inflation Adjustment The appropriate deposit subtotal is $ (Part 2 x Part 3) Part 5: Inflation Adjustment The inflation adjustment for sales year 201 is 7 percent. $ (Part 4 x ) Part 6: Escrow Deposit Paid The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for sales in Quarter 4 of year 201 is $ (Part 4 + Part 5) Part 7: Outstanding Inflation Adjustment A.The number of individual cigarettes and "roll-your-own" tobacco units (0.09 oz = 1 unit) sold by theManufacturer identified above during Quarters 1-3 of 201 = B.The deposit subtotal = $(Part 7A x $0.0188482) American LegalNet, Inc. www.FormsWorkFlow.com (Part 7B x ) (Refer to (Part 7C 226 The total inflation adjustment due for sales during Quarters 1-3 of =The estimated inflation adjustment paid for sales during Quarters 1-3 of =previous certificates of compliance for sales year )The outstanding inflation adjustment due for sales during Quarters 1-3 of =Part 7D) Part 8: Financial Institution Name of Institution: Address: Escrow Acct No: Sub-account No. for South Dakota: Total Amt Held for South Dakota: Total Balance in Escrow Account: Copies of your receipt or other proof of deposit from your financial institution, must be Attached and filed with this Certificate of Compliance. Part 9: Signature I hereby certify that the above-named manufacturer has deposited $0.0188482 for each unit sold (cigarette and "roll- your- own" tobacco as defined by SDCL 10-50B-4) in South Dakota in Quarter 4 of year , plus the inflation adjustment due for all sales in , into the above-described escrow account. Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certificate of Compliance is true and accurate. Name of Authorized Agent: Title: Signature of Authorized Agent: Date: Subscribed to and sworn to before me, a Notary Public, on this day of , . Notary Public (SEAL) My commission expires: Mail this certificate of compliance to: Office of the Attorney General Attn: Jeromy Pankratz Assistant Attorney General 1302 E. Highway 14, Suite 1 Pierre, SD 57501-8501 American LegalNet, Inc. www.FormsWorkFlow.com