CERTIFICATE OF NON-PARTICIPATING MANUFACTURER REGARDING QUARTERLY ESCROW PAYMENT STATE OF GEORGIA 2008 PART 1: TOBACCO PRODUCT MANUFACTURER’S IDENTIFICATION Company:_______________________________________________________________ Address:________________________________________________________________ Address:________________________________________________________________ Phone:____________________________FAX:_________________________________ Email: ________________________ Web Address: Name/Title of Person Completing Report: _____________________________________ If located in the U.S.: Manufacturer’s Federal I.D. #: If located in the U.S.: TTB Tobacco Manufacturer Permit Number: PART 2: SALES YEAR . The quarter being reported is (check one): The sales year for this certificate is Jan.-Mar. Apr.-June July-Sept. Oct.-Dec. PART 3: BRAND SALES A. The number of individual cigarettes or units of Roll Your Own tobacco sold in Georgia during the period specified above is as follows (.09 oz. of Roll Your Own tobacco equals one unit): Brand Name: ____________# of cigarettes Brand Name: ____________# of cigarettes Brand Name: ____________# of cigarettes or units sold:_________ or units sold:_________ or units sold:_________ Total cigarettes or ounces sold: B. The party listed in Part 1 (check one) listed above. is is not the fabricator of the brands C. For each brand listed above, list the name and address of any other manufacturer who fabricated the brand in the preceding or current calendar year: Form AG-04 (Rev. 3/08) 468253 American LegalNet, Inc. www.FormsWorkflow.com PART 4: CALCULATING THE DEPOSIT AMOUNT Follow these steps to calculate the appropriate amount to be deposited for quarterly period: (a) Enter the total number from Part 3 Section A above: ________ (b) Multiply that amount by .0258601: x .0258601 This is the amount provided in O.C.G.A. § 10-13-3, with the minimum required inflation adjustment for the 2008 sales year. The actual inflation adjustment for 2008 sales will not be available until 2009 and may be higher that the amount provided above. You are responsible for accounting for any additional inflation adjustment in your yearly certification. (c) Enter the total here: The amount that must be deposited for the quarterly period will be the amount shown in Line 4(c). Attach a copy of your receipt or other proof of deposit from your financial institution. PART 5: QUALIFIED ESCROW FUND – FINANCIAL INSTITUTION The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account. Name of Institution: Address: Phone:_________________________ Representative’s Name: Escrow Acct No:_________________________ State Account No: Total amount held in this account solely for the State of Georgia: PART 6: EXECUTION BY AUTHORIZED DESIGNEE By executing this document I confirm that I am a qualified company officer authorized to bind the applicant company. Under penalty of perjury, I state that the information contained in this Certification is true and accurate. Designee (Print Name): ______________________________ Title: Signature of Designee: _______________________________ Date: Subscribed and sworn to before me on this date: Signature of Notary Public: ___________________ City or County of: ________ My Commission expires: Mail the completed certificate of compliance to: Consumer Interests Section Office of the Attorney General 40 Capitol Square, Atlanta, Georgia 30334 Form AG-04 (Rev. 3/08) 468253 American LegalNet, Inc. www.FormsWorkflow.com