SOUTH DAKOTA Certificate of Compliance Non-Participating Manufacturer Escrow Payment South Dakota Codified Law Ch. 10-50B 2007 Sales Reporting Period Deposit Due: April 15, 2008 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 trade mark and differentiated from one another by means of additional modifiers or descriptors, including menthol, lights, kings, and 100s 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 2007 is as follows: __________________________________________________________________________________ Part 3: Escrow Rates and Payments For the sales year 2007, the rate per cigarette is . . . . . . . . $0.0188482 Part 4: Escrow Deposit Due Without Inflation Adjustment The appropriate deposit subtotal is $ ___________________________________________(Multiply units in Part 2 by rate in Part 3) Part 5: Inflation Adjustment The appropriate inflation adjustment for the sales year 2007 is 33.20594 percent (as provided in the Master Settlement Agreement). For payments due April 15, 2008, multiply escrow deposit due in Part 4 by 33.20594% (0.3320594) and enter the result: $ __________________________________________ Part 6: Escrow Deposit Paid The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for the sales in year 2007 is $ ___________________________________ (Add Part 4 and Part 5) Part 7: 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: ________________________ [Form continues on next page] 1 American LegalNet, Inc. www.FormsWorkflow.com A copy of your executed escrow agreement, and any amendment to the escrow agreement, and copies of your receipt or other proof of deposit from your financial institution, must be attached and filed with this Certificate of Compliance. Part 8: Signature I hereby certify that the above-named manufacturer has deposited $0.0188482 for each unit (cigarette and "roll-your-own" tobacco as defined by SDCL 10-50B-4) sold in South Dakota in the year 2007, plus the inflation adjustment due, in the abovedescribed 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: Bobbi J. Rank Assistant Attorney General 1302 E. Highway 14, Suite 1 Pierre, SD 57501-8501 2 American LegalNet, Inc. www.FormsWorkflow.com