SOUTH DAKOTA Certificate of Compliance Non-Participating Manufacturer Escrow Payment South Dakota Codified Law Ch. 10-50B 2011 Sales Reporting Period Quarter 3 Deposit Due: November 30, 2011 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, 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 3 of 2011: ______________________ 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 2011, 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: Estimated Inflation Adjustment The estimated inflation adjustment for Quarter 3 of sales year 2011 is 49.92446%. $_____________________ (Part 4 x 0.4992446) 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 3 of year 2011 is $ __________________________ (Add numbers in Part 4 and Part 5) 1 American LegalNet, Inc. www.FormsWorkFlow.com 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: _____________________ 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 sold (cigarette and "rollyour-own" tobacco as defined by SDCL 10-50B-4) in South Dakota in Quarter 3 of year 2011, plus the estimated inflation adjustment due, 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: Donald E. Tinklepaugh Assistant Attorney General 1302 E. Highway 14, Suite 1 Pierre, SD 57501-8501 2 American LegalNet, Inc. www.FormsWorkFlow.com