Rev. (03/19) Page 1 of 3 COMMONWEALTH OF VIRGINIA Compliance Certification by Non-Participating Manufacturer (Quarterly Deposits made for 2019 Cigarette Sales) Part 1: Tobacco Product Manufacturer Identification Full Legal Name: Address: Contact: Phone: Fax: Email: Part 2: Sales Quarter Ending: (Day, Month, and Year) Quarters end: March 31 (escrow deposit due May 15; this certification and confirming statement from Escrow Bank must be received in the Virginia Attorney General222s Office by May 31); June 30 (escrow deposit due August 15; this certification and confirming statement from Escrow Bank must be received in the Virginia Attorney General222s Office by August 31); September 30 (escrow deposit due November 15; this certification and confirming statement from Escrow Bank must be received in the Virginia Attorney General222s Office by November 30); December 31 (Escrow deposit due April 15 of following year; this certification and confirming statement from Escrow Bank must be received in the Virginia Attorney General222s Office by April 30). Part 3: Units Sold Number of individual cigarettes sold in the Commonwealth of Virginia, whether directly or through a distributor, retailer or similar intermediary or intermediaries, during the Sales Quarter, as measured by excise taxes collected by the Commonwealth on cigarette packs bearing the excise tax (revenue) stamp of the Commonwealth. Units Sold Brand Family(s): American LegalNet, Inc. Rev. (03/19) Page 2 of 3 Part 4: Escrow Rates and Deposit Amounts Explanation concerning inflation adjustments on quarterly payments: Va. Code Section 3.2-4201 requires escrow deposits to be 223adjusted for inflation.224 Va. Code Section 3.2-4200 defines 223adjusted for inflation224 as increases in accordance with the formula for inflation adjustment set forth in Exhibit C to the Master Settlement Agreement. Each year, this calculation applies an inflation rate of 3% or the actual inflation rate, whichever is greater. The actual inflation rate for the calendar year will not be known until January of the following year. Consequently, for the first three quarters, the escrow deposits due should be calculated using a projected escrow rate based on a 3% inflation percentage for the year. That projected rate is indicated below. The actual inflation rate for the year will become available in January of the following year, and at that time an actual escrow rate for the year, including inflation, will be inserted into the appropriate blank space below on this form as it will appear on the Office of the Attorney General website at www.oag.state.va.us To determine its Fourth Quarter escrow deposit, the manufacturer should multiply its total units sold during the calendar year times the actual (i.e., newly announced) escrow rate, to get the total of escrow deposits due for the year. The manufacturer should then subtract the total of the first three quarters222 escrow deposits that have already been made, to arrive at the amount of escrow that is due for the Fourth Quarter. For First Three Quarterly Deposits: For 2019 sales, the projected escrow rate per cigarette, including the inflation adjustment, is $0.0357965. Quarterly Deposit Total: = $ (Units Sold during quarter x projected escrow rate per cigarette) For Fourth Quarter Deposits Only: Total Escrow Due for Sales Year 2019: (Total units sold for all four quarters x actual escrow rate per cigarette of ). $ Subtract Total Amount of Escrow Deposited for First Three Quarters- $ Fourth Quarter Escrow Deposit Due: = $ Note: If Manufacturer is also depositing escrow on RYO tobacco sales, add total cigarette escrow deposit from above to the RYO tobacco escrow total from page 2 of Certificate of Compliance for RYO Tobacco sales (quarterly), and make one combined deposit, for cigarettes and RYO tobacco, to the escrow account. Proof of deposit in form of statement of account from Financial Institution and anyamendments to the qualified escrow agreement must be attached to this ComplianceCertification. American LegalNet, Inc. Rev. (03/19) Page 3 of 3 Part 5: Financial Institution for Qualified Escrow Fund Agent: Institution: Address: Phone: Fax: Email: Escrow Account: Commonwealth of Virginia (Sub)Account: Cumulative Deposit Amount (all Sales Years) for sales in Virginia: $ Part 6: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that the information contained in this Compliance Certification is true, correct and complete, and that I am a qualified company officer authorized to bind the Tobacco Product Manufacturer filing this Certification. Name: Title: Phone: Fax: Email: Date: Signature: Notary: City/County of Subscribed and sworn to before me on this date: Signature: My commission expires: Mail fully executed Compliance Certification to: Tobacco Enforcement Unit Office of the Attorney General 202 N. 9th Street Richmond, Virginia 23219 American LegalNet, Inc.