STATE OF VERMONT QUARTERLY Certificate of Compliance by Non-Participating Manufacturer Quarterly Escrow Payments for Sales in 2011 GENERAL INFORMATION AND INSTRUCTIONS Who is required to file this Quarterly Certificate of Compliance? Any Non-Participating tobacco product Manufacturer (NPM) whose cigarettes are sold in the State of Vermont, whether directly or through a distributor, retailer, or similar intermediary, must annually, on or before April 30th of each year, execute and deliver to the Office of the Attorney General an Annual Certificate of Compliance. Those NPMs that: • have not previously established and funded a Qualified Escrow Fund on behalf of Vermont • have not made any escrow deposits for more than one year, or • have failed to make a timely or complete escrow deposit in the past must make quarterly escrow deposits and file a Quarterly Certificate of Compliance. In addition, the Attorney General may require quarterly escrow deposits and certificates from NPMs that have sales of more than 1,600,000 units in a calendar quarter, or if the Attorney General has reasonable cause to believe that the NPM may not make its full annual escrow deposit by the April 15th deadline. The Quarterly Certificate of Compliance must be filed in addition to the Annual Certificate of Compliance which all NPMs must submit and the Tobacco Product Manufacturers' Certification which all tobacco product manufacturers must file before their product(s) can be listed in Vermont's Directory and approved for sale in Vermont. When is this Quarterly Certificate of Compliance due? This Quarterly Certificate of Compliance must be received by the Attorney General on or before 40 days after the end of the quarter for which it is submitted. The calendar year is divided into the following quarters: 1st — January 1 through March 31 2nd — April 1 through June 30 3rd — July 1 through September 30 4th — October 1 through December 31 Quarterly Certificates of Compliance must be received on or before May 10, August 10, November 10, and February 10. When must I make my Quarterly Escrow payment? Quarterly escrow payments must be deposited into your Qualified Escrow Fund on or before 30 days after the end of the quarter in which the sales were made (April 30, July 30, October 30, and December 30). American LegalNet, Inc. www.FormsWorkFlow.com SPECIFIC INSTRUCTIONS: Part 1: Manufacturer's Identification. Identify your name, physical address, mailing address, and website address if there is a website. Indicate the name and title of the individual completing this Certificate and identify his/her email address and telephone and fax numbers. Part 2: Sales Quarter/Year. Indicate 1st, 2nd, 3rd, or 4th Quarter of 2011. Part 3: Units Sold. Write the number of individual cigarettes and units of "roll-your own" (RYO) tobacco manufactured by you and sold in Vermont during the sales quarter. (Units = Ounces divided by .09) Part 4: Escrow Rate and Payment. Multiply the number of cigarettes and units of RYO sold in the quarter by .0282581, the 2011 estimated per-stick escrow deposit rate. Part 5: Financial Institution. Write the name and address of the financial institution holding your escrow account. Include your escrow account number. Also write the total cumulative amount currently in your escrow account for the benefit of the State of Vermont. Proof of deposit must be provided to the Attorney General. Part 6: Signature. This form must be signed and dated by an officer or director of your company and that person's name and title must be legibly printed. An authorized notary public must also sign and date the Certificate. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF VERMONT Certificate of Compliance by Non-Participating Manufacturer 2011 QUARTERLY Escrow Payment for Sales in (Due May 10, August 10,and November 10, 2011 and February 10, 2012) Part 1: Manufacturer's Identification Name:____________________________________________________________________ PhysicalAddress:___________________________________________________________ Mailing Address: __________________________________________________________ Website Address: ____________________________________________ Name/Title of Person Completing Certificate: ________________________________________________________________________ Phone: ___________________ Fax: __________________ Email:___________________________ Part 2: Sales Quarter/Year The Quarter of Sales for this Certificate of Compliance is: _________(quarter) of 2011. Part 3: Units Sold Number of individual cigarettes and “units” of roll-your-own tobacco, sold in Vermont by the Manufacturer during the sales quarter identified above is: _________________ (“Units” = Ounces divided by .09). Part 4: Escrow Rate and Payment The estimated per/stick escrow deposit rate for 2010 sales is $ .0274350. The total amount that has been paid into the Qualified Escrow Fund by the Manufacturer for the quarter identified above is: $ _________________ (Multiply units in Part 3 by .0282581) American LegalNet, Inc. www.FormsWorkFlow.com Part 5: Financial Institution Name of Institution: ________________________________________________________________________ Address:__________________________________________________________________ Escrow Account Number: __________________________________________________ Total amount held for the State of Vermont: $ _____________________________ Part 6: Signature Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this Annual Certificate of Compliance is true and accurate. This Annual Certificate of Compliance must also be signed and dated by an authorized notary public. Name/Title of Authorized Agent: (Must be an officer or director of the Manufacturer) Name: ____________________________________ Title: ___________________________ Signature of Authorized Agent: _______________________________________________ Date: _____________________________ Subscribed and sworn to before me on this date: ______________________________, in the City or County of__________________________, State of ____________ , Country of _______________________ . Signature of Notary Public: ________________________________________________ My Commission expires: ________________________ Mail this Certificate of Compliance to: Tobacco Enforcement Unit Office of the Attorney General of Vermont 109 State Street Montpelier, Vermont 05609-1001 tobacco@atg.state.vt.us Revised February 15, 2011 American LegalNet, Inc. www.FormsWorkFlow.com