Official TN Form 86821 10/28/2005 State of Tennessee Affidavit of Tobacco Product Manufacturer REQUIRED ATTACHMENT TO CERTIFICATION APPLICATION Please complete (may be filled out on-line) and execute in blue permanent ink and send signed originals to the Tennessee Attorney General’s Office and the Tennessee Department of Revenue at the two addresses listed in the Certification instructions. An authorized officer of the Tobacco Product Manufacturer MUST sign this form and check the correct box below. This form must also be notarized. Under penalty of perjury, I state that the Tobacco Product Manufacturer named in Part 1 as of the date of this Certification, is a Participating Manufacturer in full compliance with all applicable sections of Tenn. Code Ann. §§ 67-42601, et seq. and any rules and regulations promulgated thereunder. OR Under penalty of perjury, I state that the Tobacco Product Manufacturer named in Part 1 as of the date of this Certification, is a Non-Participating Manufacturer in full compliance with all applicable sections of Tenn. Code Ann. §§ 67-4-2601, et seq. and any rules and regulations promulgated thereunder. Additionally, the Tobacco Product Manufacturer identified in Part 1 fabricated or assembled the brand families listed herein that were sold in Tennessee during the calendar year stated herein. Under penalty of perjury, I also state: (1) On behalf of the Tobacco Product Manufacturer named in Part 1, the Applicant is familiar with and will comply with all state and federal laws, rules and regulations regarding the sale of tobacco products and Cigarettes in Tennessee, including but not limited to, the Tennessee Tobacco Manufacturers Escrow Act of 1999, Tenn. Code Ann. §§ 47-31-101, et seq. and the directory statute located at Tenn. Code Ann. §§ 67-4-2601, et seq; (2) I understand that the Attorney General or the Department of Revenue may require additional information and/or documentation to determine if the Applicant qualifies for listing on Tennessee’s Directory; (3) I acknowledge that the Applicant has a duty to file an annual Certification and to supplement its application within 30 calendar days of its discovery that any information or documents contained in the Certification is inaccurate, incomplete or misleading; (4) I have read this Certification and the attached documents, and reviewed the Instructions and Definitions and to the best of my knowledge and information, this Certification has been completed in compliance with those instructions and definitions; (5) To the best of my knowledge, this Certification and its attachments are a complete, accurate, non-misleading and truthful response of the Applicant Tobacco Product Manufacturer; (6) On behalf of the Applicant, I hereby authenticate this Certification and its attachments for the purposes of any proceedings pursuant to any rules of procedure. These documents are authentic and true and accurate copies of Applicant’s official records. The Applicant will not contest or object to the use of this Certification and its attachments in any proceeding; and (7) I am an authorized representative of the Applicant Tobacco Product Manufacturer with authority to bind the Applicant and submit this Certification to the State of Tennessee on its behalf. By signing this Affidavit on behalf of the Applicant company, I am stating I have the necessary authority on behalf of the Applicant to sign this Affidavit and bind the Applicant. Printed Name of Officer of Tobacco Product Manufacturer Title Signature of Authorized Officer Date Subscribed and sworn to before me on County of , 200 , in the State of and Print Name of Notary Public: Signature of Notary Public: Date Notary Commission Expires: Important Note: The State will not process incomplete, unsigned or illegible certification forms or affidavits. Only Official State forms will be process by the State. American LegalNet, Inc. www.FormsWorkflow.com