State of Utah Non-Participating Manufacturer Certification of Additional Information P. 1 of 3 Part 1: Liability Year and Type of Certification Liability Year for this Certification: 9 2007 9 Other _______ 9 Original Type of Certification: (Check one) 9 Supplemental Part 2: Manufacturer Identification Company Name Mailing Address City State Country Fax Phone Zip Code FEIN Part 3: NPM Status References to cigarettes (includes roll-your-own) are to the brand families certified on the Certificate of Compliance form submitted by the manufacturer identified in Part 2. 9 9 9 Yes 9 9 Yes 9 Yes No NPM is the fabricator of the brand families listed on the Certificate of Compliance form. No NPM manufactures cigarettes anywhere and intends for the cigarettes to be sold in the U.S. through an importer. No NPM is the first purchaser anywhere for resale in the U.S. of cigarettes manufactured any where that the manufacturer does not intend to be sold in the U.S. , Part 4: Additional Information Requested by Attorney General=s Office A. All NPMs must provide the information requested in this section. 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 as an 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 certified in Part 2 of the Certificate of Compliance form. 3. A copy of the corporate documents, such as articles of incorporation, charter or certificate. 4. A listing of all company officers and owners (all persons with an equity interest of 10% or more in company). 5. A complete list of cigarettes (including roll-your-own tobacco) that NPM, its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold: time periods for manufacture of those brands; and place of manufacture for those brands. 6. A complete list of other tobacco products (e.g. cigars, pipe tobacco, smokeless tobacco, etc.) that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufactures for those brands. American LegalNet, Inc. www.FormsWorkflow.com State of Utah Non-Participating Manufacturer Certification of Additional Information P. 2 of 3 Part 4 (continued) 7. A complete list of Little Cigars that NPM and its principals, subsidiaries, affiliates, successors, members, officers, owners and directors manufacture no matter where sold; time periods for manufacture of those brands; and the place of manufacture for those brands. 8. A list of prior manufacturer of each of the brand families certified in Part 2 of the Certificate of Compliance certification form 9. For each brand family certified in Part 2 of the Certificate of Compliance form, provide the following: a. location of manufacture b. name, address and phone number of the factory manager(s) c. the date manufacturing first commenced d. identification of intended distributors e. the price at which you intend to sell each brand family to distributers licensed in Utah f. explanation of manufacturing process and the precise activities that constitute fabrication of the cigarettes or roll-your-own tobacco g. the name, address and contract for the fabricator, if other than the NPM, and a copy of any agreement or contract between the fabricator and NPM regarding the manufacture and/or sale of cigarettes 10. If NPM or any of its principals previously imported or distributed cigarettes or roll-your-own tobacco in the U.S., list each brand family name and the manufacturer name and address for each brand family. 11. If NPM delivers cigarettes directly to a distributor located in and licensed to stamp in Utah, list all distributors located in and licensed to stamp in Utah to whom cigarettes were delivered and attach copies of the TC-553S reports filed with the Utah Tax Commission for deliveries for the last 12 months 12. For each brand family of roll-your-own tobacco being certified, state whether NPM pays the Utah tax and provide a complete list of retailers to whom the roll-your own tobacco is intended to be sold in Utah. 13. If NPM intends to sell any cigarettes or roll-your-own by mail order or through the internet, provide the internet website and/or identify publications. Attach copies of all reports, if any, filed with the Utah 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 certified in Part 2 of Certificate of Compliance form, provide the name and address of the entity that submitted the ingredient reporting information to the U.S. Secretary of Health and Human Services and required by the Federal Cigarette Labeling and Advertising Act (15 U.S.C. ' 1335a) and attach copies of all certificates of compliance. 15. For each brand family certified in Part 2 of the Certificate of Compliance form, provide 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 submitted by NPM is encumbered by granting a third party security interest in the escrow fund, provide UCC filings and Security Agreement pertaining to this security interest in the escrow fund. 17. Provide a list of states that have certified NPM and the brand families certified. If any state has refused to list or removed NPM from a state=s directory, identify the state(s). (Continued on following page) American LegalNet, Inc. www.FormsWorkflow.com State of Utah Non-Participating Manufacturer Certification of Additional Information P. 3 of 3 Part 4 (continued) B. NPMs located in foreign countries must provide the information requested in this section. All attachments must indicate the question to which it corresponds. 1. Copy of the license, permit or other registration documents required by the country where the brand families certified in Part 2b of Certificate of Compliance are manufactured. 2. Copies of Custom Form 7501for 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 precise 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. ' 1681a(c)(3)(B). 6. Name, address and contract information for all importers of the brand families certified in Part 2 of the Certificate of Compliance form. Part 5: Manufacturer Certification Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certification and any attached documents are true and accurate. This document must be signed and dated by an authorized notary public. ____________________________________________ NPM Authorized Designee (Print Name) _______________________________________________ Title ____________________________________________ Signature of NPM Authorized Designee _______________________________________________ Date Subscribed and sworn to before me this date: _______________________________________________ Signature of Notary Public County______________________ Commission Expires______________________________ American LegalNet, Inc. www.FormsWorkflow.com