STATE OF TENNESSEE OFFICE OF THE ATTORNEY GENERAL TOBACCO ENFORCEMENT DIVISION P. O. BOX 20207 NASHVILLE, TENNESSEE 37202-0207 NON-PARTICIPATING MANUFACTURER’S REQUEST FOR “UNITS SOLD” INFORMATION I. Company Information (a) Non-Participating Manufacturer:_________________________________________ (b) Address:____________________________________________________________ (c) Telephone:___________________________________________________________ (d) Fax:________________________________________________________________ (e) Authorized Representative Making Request:________________________________ II. Request for “Units Sold” Information On behalf of the above-identified Non-Participating Manufacturer, ____________________________________, hereby request that the Tennessee Office of (Authorized Representative) Attorney General Tobacco Enforcement Division (hereinafter the “State”), disclose the number of “Units Sold”, as defined at Tenn. Code Ann. § 47-31-102(10), for the following brand families:_____________________________________________________, sold in Tennessee (NPM Brand Families) during the following time period:__________________. (year/quarter) By executing this request form, I acknowledge that the State has the authority to revise its calculation of the number of Units Sold if any new or amended information is received at any time. I further acknowledge that the above-identified Non-Participating Manufacturer is required to track its sales occurring in Tennessee in accordance with Tenn. Code Ann. § 47-31-103. 1 American LegalNet, Inc. www.FormsWorkFlow.com III. Manufacturer’s Totals for Units Sold During ______________________________ (Year/Quarter) (Please fill out a separate line for each brand family sold by a wholesaler) Name and Address of Wholesalers licensed in Tennessee to whom tobacco products were shipped.* Brand Family Sold Number of Units Shipped *This also applies to wholesalers located out-of-state who are licensed to do business as a Tennessee wholesaler. 2 American LegalNet, Inc. www.FormsWorkFlow.com III. Confidentiality Agreement On behalf of the above-identified Non-Participating Manufacturer, I, _____________________________________, hereby agree not to disclose the Units Sold (Authorized Representative) information provided by the State in response to this request, including wholesaler data collected by the Tennessee Department of Revenue, to anyone other than employees and representatives of the above-named Non-Participating Manufacturer. IV. Signature __________________________________ Authorized Representative ___________________________________ Date 3 American LegalNet, Inc. www.FormsWorkFlow.com