Rev. (01/17) COMMONWEALTH OF VIRGINIA Certification of No Sales by Non-Participating Manufacturer (Yearly Deposits; RYO) Part 1: Tobacco Product Manufacturer Identification Full Legal Name: Address: Contact: Phone: Fax: Email: Part 2: Date this certification was executed For Sales Year: (Complete a separate Certification for each Sales Year) Part 3: Brand Family(s): Part 4: Certification The Tobacco Product Manufacturer certifies that the company: (1) has elected not to become a participating manufacturer (as that term is defined in section II (jj) of the Master Settlement Agreement) and generally perform its financial obligations under the Master Settlement Agreement; and (2) has not sold any RYO Tobacco in the Commonwealth of Virginia, whether directly or through a distributor, retailer or similar intermediary or intermediaries, during the Sales Year, as measured by excise taxes collected by the Commonwealth on shipments of RYO tobacco. Part 5: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that the information contained in this Certification of No Sales is true, correct and complete, and that I am a qualified company officer authorized to bind the Tobacco Product Manufacturer filing this Certification of No Sales. Name: Title: Phone: Fax: Email: Date: Signature: Notary: City/County of Subscribed and sworn to before me on this date: Signature: My commission expires: The Certification of No Sales is due by April 30 of the year following the Sales Year. Mail fully executed Certification of No Sales to: Tobacco Section Office of the Attorney General 202 N. 9th Street Richmond, Virginia 23219 American LegalNet, Inc. www.FormsWorkFlow.com