Utah State Tax Commission 210 N 1950 W Salt Lake City UT 84134 TC-752 Utah Certificate of Compliance by Tobacco Product Manufacturer Rev. 4/11 Read the instructions carefully before filing this certification. We will reject incomplete or illegible certifications. PART 1: Tobacco Product Manufacturer A. Company Information Company name Address City State ZIP Code Country Telephone number Fax number Email address Website URL Name/title of person completing this form Name/title of contact person at company Address of manufacturing plant(s) Name of factory manager(s) Telephone number of factory manager(s) Fax number of factory manager(s) Manufacturer’s FEIN (if located in U.S.) Manufacturer’s TTB permit number Permit expiration date B. As of the date of this certification, the manufacturer is: A participating manufacturer A non-participating manufacturer (NPM) Complete Parts 1, 2A, 3 and 7. Complete entire form except 2A Submit Federal Approvals (see instructions) Attach all required information (see instructions) C. This form is (check only one): Initial certification — Manufacturer is not currently on the Utah Approved Tobacco Manufacturers and Cigarette/RYO Brands list Annual certification — Due May 2, 2011 for Utah sales in 2010 Supplemental certification — Change of information previously provided to the Utah State Tax Commission You MUST submit change of information 30 DAYS prior to the change. PART 2: Brand Family Identification See instructions. A. Participating Manufacturers 1. Brand Family Name 2. Product Type 3. Fire Safe 4. Sales in Utah Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Attach additional sheets as needed. TC-752, page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com B. Non-Participating Manufacturers (NPM) 1. Brand Family Name 2. Product Type 3. Fire Safe 4. Sales in Utah Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes No No Cigarette RYO Yes No Past: Future: Yes Yes 5. Units* Sold 6. Previous Manufacturer in Utah, 2010 (name & address) No No Attach additional sheets as needed. *One unit equals one cigarette or .09 oz. of RYO. Provide a sample of the packaging of EACH brand family unless you have already provided a sample and it has not changed. Check here if you have previously submitted all packaging samples and they have not changed. PART 3: Local Distributor (UCA §59-14-205) List the names and addresses of Utah-licensed distributors selling your product(s) in or into Utah. If you do not have a Utah-licensed distributor your product cannot be listed as approved for sale in Utah. Distributor Name UT Lic. Number Distributor Address Phone Number Brand _____________ ________ _______________ _______ _____ __ __ __ _____________ ________ _______________ _______ _____ __ __ __ _____________ ________ _______________ _______ _____ __ __ __ _____________ ________ _______________ _______ _____ __ __ __ _____________ ________ _______________ _______ _____ __ __ __ _____________ ________ _______________ _______ _____ __ __ __ Attach additional sheets as needed. PART 4: NPM Registered Agent Check one: The non-participating manufacturer (from Part 1) is registered to do business in Utah. The non-participating manufacturer (from Part 1) has appointed and continues to engage the following agent located in Utah: Name of registered agent Address City Telephone number State ZIP Code Email address Fax number You must attach a CURRENT (dated this year) letter from the registered agent accepting this appointment. We will reject incomplete or illegible certifications. TC-752, page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PART 5: NPM Status In the following questions, “products” means cigarettes and RYO tobacco. Yes No NPM is the maker of the products listed in Part 2B. Yes No NPM manufactures products anywhere and intends for them to be sold in the U.S. through an importer. Yes No NPM is the first buyer anywhere for resale in the U.S. of products made anywhere that the manufacturer does not intend to be sold in the U.S. PART 6: NPM Qualified Escrow Account A. Escrow account information (UCA §59-14-602) The non-participating manufacturer (from Part 1) has set up and continues to maintain the following qualified escrow fund: Name of financial institution Address City State ZIP Code Country Contact name/title Telephone number Fax number Escrow account number Utah sub-account number Provide an executed copy of the current Escrow Agreement. You must also provide any amendments or attachments to the agreement. B. Escrow calculation and deposit for 2010 Utah sales 1. Total units sold in Utah during 2010 ........................................................................ 1 2. Rate per unit in 2010 ............................................................................................... 2 .0274350 3. Escrow deposit for 2010 Utah sales (multiply line 1 by line 2)................................. 3 $ You must make the deposit to your Utah segregated sub-account by April 15, 2011. C. 2010 Escrow deposit/withdrawal history for Utah You must provide verification of compliance with UCA §§59-14-602 and 59-22-203. Date Deposit Withdrawal Balance Begining balance: Deposit total: Withdrawal total: Ending balance: Attach additional sheets as needed. See instructions for documentation you must provide with this certification. We will reject incomplete or illegible certifications. TC-752, page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com PART 7: Affidavit This certification must be signed by a qualified officer of the manufacturer authorized to bind the applicant company. • By signing this certification below, I affirm my position with the company, my authority to certify on behalf of the applicant, and my authority to bind the company. • I understand the Utah State Tax Commission may require additional information and/or documentation to determine if the applicant and/or brands qualify for listing on the Utah Approved Tobacco Manufacturers and Cigarette/RYO Brands. • I have examined this certification, including attachments and supporting documents. To the best of my knowledge and belief, this certification, including attachments and supporting documents, is true, correct and complete. • I understand the company must comply with state and federal laws concerning the sale of tobacco products. • The company hereby submits itself to the jurisdiction of the Third District Court of the State of Utah for purposes of all litigation arising from this certification or the sale of tobacco products in Utah. • The company hereby waives any claim or defense of sovereign immunity with respect to litigation brought by the State of Utah arising from this certification or the sale of tobacco products in Utah. You must check one box: Participating Manufacturer: Under penalty of falsification, I state the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a participating manufacturer in full compliance with Utah Code Title 59, Chapters 14 and 22. Non-Participating Manufacturer: Under penalty of falsification, I state the tobacco product manufacturer named in Part 1A, as of the date of this certification, is a non-participating manufacturer in full compliance with Utah Code Title 59, Chapters 14 and 22. I have attached all the required information and attachments listed in items 1 through 17 of Other Information NPMs Must Provide (see TC-752 Instructions). This form must be notarized. ________________________________________ Name of officer of tobacco product manufacturer _________________ Title ________________________________________ Signature of officer _________________ Date Subscribed and sworn to me this date: ________________________________________ County of: _____________________________________________________ Signature of Notary Public: _____________________________________________ Notary commission expires: _____________________________________________ We will reject incomplete or illegible certifications. TC-752, page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com TC-752 Instructions How to File Mail the original of this completed Certificate of Compliance and all attachments to: Utah State Tax Commission Attn: Processing Division 210 N 1950 W Salt Lake City, UT 84134-3500 and a copy to: Utah Attorney General’s Office Katharine H. Kinsman Assistant Attorney General 160 E 300 S P.O. Box 140857 Salt Lake City, UT 84114-0857 General Instructions Federal Approval Required by UCA §59-14-210 For each of the brand families (cigarette only) you have sold or will sell in Utah, provide a copy of the CURRENT FTC approval letter for health-warning rotation plan. Contact: Federal Trade Commission 600 Pennsylvania Avenue, N.W. Washington, D.C. 20580 General Information Locator: 202-326-2222 Provide a copy of the CURRENT CDC ingredient-listing compliance letter(s) for the cigarette brands you have sold or will sell in Utah, including a statement of which brand’s ingredients were submitted for each approval letter. Contact: Center for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Telephone: 1-800-311-3435 www.cdc.gov/netinfo.htm Other Information NPMs Must Provide All NPMs All NPMs must provide the following information. All attachments must indicate the question to which it corresponds: 1. A copy of your current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/or importer. 2. Name, address and phone number of the trademark owner and any license agreement or other document providing permission to the NPM to use the trademark for each of the brand families listed in Part 2B. 3. A copy of the corporate documents, such as articles of incorporation, charter or certificate. 4. A list of all company officers and owners (all persons with an equity interest of 10 percent or more in the company). 5. A complete list of cigarettes and RYO tobacco that the NPM (plus its principals, subsidiaries, affiliates, successors, members, officers, owners and directors) manufactures, no matter where sold; time periods for the manufacture of those brands; and place of manufacture for those brands. 6. A complete list of other tobacco products (cigars, pipe tobacco, smokeless tobacco, etc.) that the NPM (plus its principals, subsidiaries, affiliates, successors, members, officers, owners and directors) manufactures, no matter where sold; time periods for the manufacture of those brands; and place of manufacture for those brands. TC-752 Instructions American LegalNet, Inc. www.FormsWorkFlow.com 7. A complete list of little cigars that the NPM (plus its principals, subsidiaries, affiliates, successors, members, officers, owners and directors) manufactures, no matter where sold; time periods for the manufacture of those brands; and place of manufacture for those brands. 8. A list of prior manufacturers of each of the brand families listed in Part 2B. 9. For each brand family in Part 2B, report: a. Location of manufacturer b. Name, address and phone number of the factory manager(s) c. Date manufacturing first began d. Identification of intended distributors e. Price at which you intend to sell each brand family to distributors licensed in Utah f. Explanation of the manufacturing process and the individual steps used to produce the cigarettes or RYO tobacco g. Name, address and contact for the maker (if other than the NPM) and a copy of any agreement or contract between the maker and the NPM regarding the manufacture and/or sale of cigarettes 10. If the NPM or any of its principals previously imported or distributed cigarettes or RYO tobacco in the U.S., a list of each brand family name and the manufacturer’s name and address for each brand family. 11. If the NPM delivers cigarettes directly to a distributor located in and licensed to stamp in Utah, a list of all such distributors to whom cigarettes were delivered. Attach copies of the TC-562 reports filed with the Utah State Tax Commission for deliveries during the last 12 months. 12. For each brand family of RYO tobacco being certified, a statement of whether the NPM pays the Utah tax and provide a complete list of retailers to whom the RYO tobacco is intended to be sold in Utah. 13. If the NPM intends to sell any cigarettes or RYO by mail order or through the Internet, a list of the publications and/or the Website URLs. Attach copies of all reports, if any, filed with the Utah State Tax Commission to comply with the Jenkins Act (Chapter 10A of Title 15 of the U.S. Code, Section 375 et seq.) for sales in the last 12 months. 14. For each brand family in Part 2B, the name and address of the entity that submitted the ingredient report to the U.S. Secretary of Health and Human Services as required by the Federal Cigarette Labeling and Advertising Act (15 U.S.C. § 1335a). Attach copies of all certificates of compliance. 15. For each brand family in Part 2B, a copy of the current FTC rotation plan approval letter and the name and address of the entity that filed the health warning rotation plan with the FTC. 16. If the escrow agreement the NPM submitted grants a third party security interest in the escrow fund, a copy of UCC filings and the Security Agreement relating to this security interest. 17. A list of the states that have certified the NPM and the brand families certified. If any state has refused to list the NPM or has removed the NPM from its directory, identify that state(s). Foreign NPMs NPMs located in foreign countries must provide the following information. All attachments must indicate the question to which it corresponds: 1. A copy of the license, permit or other registration documents required by the country where the brand families in Part 2B are manufactured. 2. Copies of Custom Form 7501 for the last 12 months for each brand family being certified. 3. A copy of the sworn statement that the NPM has timely submitted or has certified that it will timely submit ingredients to the Secretary of Health and Human Services, as required by 19 U.S.C. § 1681a(c)(1). 4. A copy of the importer’s certificate under penalty of perjury as required by 19 U.S.C. 1681a(c)(2) regarding the exact format of warnings and the rotation plan for health warnings. 5. A copy of the trademark holder’s certificate under penalty of perjury that it has not withdrawn consent to import into the United States as required by 19 U.S.C. § 1681a(c)(3)(A) and a copy of the importer’s certificate under penalty of perjury that the trademark owner has not withdrawn consent to import into the United States as required by 19 U.S.C. § 1681(c)(3)(B). 6. The name, address and contact information for all importers of the brand families listed in Part 2B. TC-752 Instructions American LegalNet, Inc. www.FormsWorkFlow.com Form Instructions PART 2: Brand Family Identification Only identified brand families will be certified and listed in Publication 51 (Utah Cigarette and RYO Authorized Brands). Brands not listed in Publication 51 may not be sold in Utah. Section A - Participating Manufacturers Column 1: List each cigarette brand family that you use in calculating payments under the Master Settlement Agreement. Column 2: Mark the type of product for each brand family – either cigarette or roll-your-own. Column 3: Mark “Yes” if the brand family had been certified Fire Safe by the Utah Fire Marshal’s Office. Otherwise, mark “No.” Column 4: Report whether there have been past sales in Utah and if there will be future Utah sales. • For “Past,” mark “Yes” if the brand family has ever been sold in Utah. Otherwise, mark “No.” • For “Future,” mark “Yes” if the brand family will or may be sold in Utah after the date of this certification. Mark “No” if the product will NOT be sold in Utah after the date of this certification. Section B - Nonparticipating Manufacturers Column 1: List each of your cigarette brand families. See Utah Code §§59-14-602 and 603. Column 2: Mark the type of product for each brand family – either cigarette or roll-your-own. Column 3: Mark “Yes” if the brand family had been certified Fire Safe by the Utah Fire Marshal’s Office. Otherwise, mark “No.” Column 4: Report whether there have been past sales in Utah and if there will be future Utah sales. • For “Past,” mark “Yes” if the brand family has ever been sold in Utah. Otherwise, mark “No.” • For “Future,” mark “Yes” if the brand family will or may be sold in Utah after the date of this certification. Mark “No” if the product will NOT be sold in Utah after the date of this certification. Column 5: Report the units sold in Utah during the previous calendar year. For cigarettes, one cigarette equals one unit. For RYO, .09 ounces equals one unit. Column 6: Report the name and address of the previous manufacturer. PART 6: NPM Qualified Escrow Account You must include with your certification the following: • Proof of the amount and date of deposit to Utah’s segregated sub-account for 2010 sales. • Current account ledger of your segregated sub-account for Utah. These items are part of the Certification and are due by May 2, 2011. We will reject incomplete Certifications. PART 7: Affidavit The certification must be: • Signed by an officer of the manufacturer who is authorized to bind the applicant company. • Notarized. We will reject certifications that are not signed and notarized. TC-752 Instructions American LegalNet, Inc. www.FormsWorkFlow.com