Official Form 86825 10/27/05 Page 1 of 7 State of Tennessee Certificate of Escrow Compliance Tobacco Manufacturers’ Escrow Act of 1999 Tenn. Code Ann. §§ 47-31-101 et seq. Check appropriate response: : Revised Certificate - Change of information provided to the Attorney General (Change of information must be submitted at least 30 days prior to change or no more than 30 days after discovery of inaccurate, incomplete or misleading information.) : Annual Certificate of Escrow Compliance - Due April 30 for Tennessee sales in prior calendar year. Please type or legibly print in permanent blue ink (This form may be filled out on-line. However, all signatures must be executed in permanent blue ink.) This Certificate of Escrow Compliance is for calendar year sales during year. (Insert year) Part I: General Tobacco Manufacturer Information 1. Applicant/Tobacco Product Manufacturer Identification. Applicant name: Street Address: City/State/Zip/Country: Mailing Address (if different from above): City/State/Zip/Country: Telephone number: Facsimile number: E-mail address: Website address: Name of Person Completing Certificate: Title of Person Completing Certificate: Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 2. Page 2 of 7 The Tobacco Product Manufacturer identified above, as of the date of this Certificate is (You must select one of the two boxes and initial in the box applicable to the Applicant): A Participating Manufacturer as defined by the Master Settlement Agreement and generally performing its financial obligations under the Master Settlement Agreement. OR A Non-Participating Manufacturer in full compliance with Tennessee Tobacco Manufacturers’ Escrow Fund Act of 1999, Tenn. Code Ann. §§ 47-31-101, et seq, including have made all required deposits into a Qualified Escrow Fund in all years beginning with the effective date of the Tennessee Tobacco Manufacturers’ Escrow Act of 1999 and any rules and regulations promulgated thereunder. 3. Identify by name, address, telephone number and facsimile number any attorney authorized to represent you regarding your Certificate of Escrow Compliance. (Attach additional sheets if necessary.) 4. Identify by name, title, address, telephone number and facsimile number any person authorized to provide information to the State of Tennessee or receive information from the State of Tennessee regarding your Certificate of Escrow Compliance. (Attach additional sheets if necessary) Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 Page 3 of 7 5. The Applicant is the Tobacco Product Manufacturer (i.e. fabricator) of the brand families listed in this Certificate which are intended to be sold in the United States, including Cigarettes intended to be sold in the United States through an importer. Yes No 6. The Applicant is the first purchaser anywhere for resale in the United States of Cigarettes manufactured anywhere that the Tobacco Product Manufacturer does not intend to be sold in the United States. Yes No If the answer is “Yes”, identify each Cigarette manufacturer (i.e. fabricator), its plant street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to the applicant. Identify the location of the transfer of ownership of Cigarettes and a copy of every agreement or contract between the applicant and fabricator. (Attach additional sheet(s), as necessary, to complete the response.) 7. Applicant is a successor of any entity described in questions #5 or #6 above (i.e., manufacturer or first importer). Yes No 8. If Applicant answered “No” to questions #5, #6 and #7 above, explain the basis for Applicant’s claim that it is a Tobacco Product Manufacturer as defined by Tenn. Code Ann.§ 47-31-102(9) and submit all documents to support Applicant’s contention. (Attach additional sheet(s), as necessary, to provide a complete response. ) Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 Page 4 of 7 Part II: Non Participating Manufacturer Qualified Escrow Account 9. Escrow Account Information Non-Participating Manufacturer Applicant certifies that as of the date of this Certificate, Applicant: A. Has established and continues to maintain a Qualified Escrow Fund: Yes No B. Has executed a Qualified Escrow Agreement that has been reviewed and approved by the Attorney General for the State of Tennessee and that governs that Qualified Escrow Fund for the State of Tennessee: Yes No (Please note the model Tennessee’s Escrow Agreement is available on the Tennessee Attorney General’s Website at http://www.attorneygeneral.state.tn.us) C. The Qualified Escrow Agreement submitted to the Attorney General for the State of Tennessee No is identical to the one provided on the Tennessee Attorney General’s Website? Yes If you answered “no” to # 9c, please review and comply with the Instructions and Definitions. You are required to provide a redlined version of the Escrow Agreement for prior approval in writing by the Attorney General of the alterations. The redline copy must include double underlined markings of all additions and strike out markings of all deletions to the model Escrow Agreement. 10. Financial Institution information: Name of Institution: Representative Name/Title: Street Address: City/State/Zip Code: Escrow Acct. #: Sub-Acct. # For Tennessee: Telephone Number: Facsimile Number: Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 11. Page 5 of 7 Escrow calculation and deposit for sales in Tennessee for calendar year sales. A. Identify sales calendar year: B. Number of Units Sold, by brand, in Tennessee during the applicable sales year (use additional paper as necessary): Brand Family C. D. Number of Units Sold Total number of Units Sold in Tennessee during the applicable sales year: Amount of Deposit (see instructions and definitions, statute and applicable rules and regulations for details): $ DEPOSIT TO TENNESSEE SEGREGATED SUB-ACCOUNT MUST BE MADE BY NO LATER THAN APRIL 15. 12. Escrow Deposit/Withdrawal History for the State of Tennessee (attach additional sheets if necessary): Withdrawals must comply with Tenn. Code Ann. §§ 47-31-101, et seq and any rules and regulations promulgated thereunder and verification of compliance must be provided. Date Deposit Total: Q Important Note: Withdrawal Total: Balance Total: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 Page 6 of 7 13. The Financial Institution noted in Part 2 Section 10 of this Certificate is required to provide directly to the Tobacco Enforcement Division of the Tennessee Attorney General’s Office the following: A. Proof of the amount and date of the deposit to Tennessee’s segregated sub-account for stated sales year. Check this box to verify that the required information has been provided. B. Current account ledger of the tobacco product manufacturer’s segregated sub-account for Tennessee. Check this box to verify that the required current account ledger has been provided. NOTE: These items are part of the Certificate and are due by no later than April 30. Part III. Additional Information General Company Information. 14. Indicate whether the following statements describe the Applicant by marking either yes or no after the statement: A. B. Applicant made escrow deposits pursuant to Tennessee’s Escrow Fund Act, Tenn. Code Ann. §§ 47-31-103, et seq and any rules and regulations promulgated thereunder in the preceding year: Yes9 No 9 C. Applicant sold in the preceding calendar year one or more of the Brand Families listed in this Certificate: Yes9 No 9 D. Applicant made escrow payments in the preceding year pursuant to Tennessee’s Escrow Fund Act for one or more of the Brand Families listed in this Certificate: Yes9 No 9 E. There has been a change in Tobacco Product Manufacturer (i.e., fabricator) or one or more of the Brand Families listed in this Certificate within the past two calendar years: Yes9 No 9 F. L Applicant sold Cigarettes in Tennessee in the preceding calendar year: Yes9 No 9 Applicant failed to timely file any completed form or document required by the Tennessee Escrow Statute: Yes9 No 9 Please note the State has the right to request additional information. You will receive a letter(s) requesting additional information if the State so elects. You application will not be complete until all information requested in any letters from the State is also provided. GO TO NEXT PAGE FOR SIGNATURE AND VERIFICATION FORM Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com Official Form 86825 10/27/05 Page 7 of 7 Part IV. Signature and Verification of Applicant Tobacco Product Manufacturer’s Representative Under penalties of perjury and falsification, I hereby state and swear that: (A) On behalf of the Tobacco Product Manufacturer named herein, 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. and any rules and regulations promulgated thereunder; (B) 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 above; (C) I have read this Certificate of Escrow Compliance and the attached documents, and reviewed the Instructions and Definitions and to the best of my knowledge and information, this Certificate has been completed in Compliance with those Instructions and Definitions; (D) To the best of my knowledge, this Certificate of Escrow Compliance and its attachments are a complete, accurate, non-misleading and truthful response of the Applicant Tobacco Product Manufacturer; (E) On behalf of the Applicant, I hereby authenticate this Certificate of Escrow Compliance 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 Certificate of Escrow Compliance and its attachments in any proceeding; (F) I understand that the Attorney General or the Department of Revenue may require additional information and/or documentation including, but not limited to, documentation to determine if the Applicant qualifies for listing on Tennessee’s Directory; (G) I acknowledge that the Applicant has a duty to file an annual Certification and to revise its application within 30 calendar days of its discovery that any information or documents contained in the Certification is inaccurate, incomplete or misleading; and (H) I am an authorized representative of the Applicant Tobacco Product Manufacturer with authority to bind the Applicant and submit this Certificate of Escrow Compliance to the State of Tennessee on its behalf. Printed name of authorized representative Signature of authorized representative Date Title State of ) County of ) Personally sworn to and subscribed before me the day of , 20 . My commission expires: Signature of Notary Public Q Important Note: The Attorney General’s Office will not process incomplete, unsigned or illegible certificates. Only State official forms will be processed by the State. American LegalNet, Inc. www.FormsWorkflow.com