Washington Certificate of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Part 1: Manufacturer’s identification 1. 2. 3. 4. 5. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ Telephone number: ___________________________________________________________________________________________ Electronic mail address:________________________________________________________________________________________ Part 2: Liability quarter/year Complete only one year of liability on this form. 6. The liability quarter/year for this certificate is: __________________________ Part 3: Units sold 7. Number of individual cigarettes and roll-your own sold by the manufacturer identified above during the liability year bearing Washington cigarette tax stamps is as follows: Part 7__________________________ 4: Deposit amount The rates listed below are the yearly base rates. For the liability year: 1999 (for after May 18, 1999 only), the rate per cigarette is….0.0094241 2000, the rate per cigarette is ...........................……………….0.0104712 2001, through 2002, the rate per cigarette is ……….…..….…0.0136125 2003, through 2006, the rate per cigarette is .………….……..0.0167539 2007 and thereafter, the rate per cigarette is .....………………0.0188482 *8. Multiply Line 7 by 0.0282581 (2011 combined base rate plus estimated annual inflation rate) and enter the amount in line 8A: Total Escrow Paid 8A__________________________ Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the current escrow agreement between you and the institution. Part 5: Financial institution 9. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ 10. Escrow account number _____________________________ Total amount held in this account $_____________________________ Part 6: Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. Sworn to and subscribed before me this ________ day of ___________________, 2011 _________________________________________________ Signature of Notary Public _______________________________________________________ Print the name of authorized agent Title _______________________________________________________ Signature of authorized agent Date City / State: _______________________________________ My commission expires ________/__________/__________ * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. The form should be sent to either the following mailing address or if by courier, to our geographical address: Attorney General’s Office Revenue Division PO Box 40123 Olympia, WA 98504-0123 OR Attorney General’s Office Revenue Division 7141 Cleanwater Drive SW Tumwater, WA 98501 American LegalNet, Inc. www.FormsWorkFlow.com