STATE OF WYOMING NON-PARTICIPATING MANUFACTURER CERTIFICATION FORM Attachment A Please provide the following information, only for brands being certified for sale in the State of Wyoming: Bolded, italicized questions indicate attachments required. All other questions can be answered on the form. If you need more space to answer questions, please attach additional sheets. 1. Identify the trademark owner for the brand/s being certified: Name and Address:_______________________ ___________________________________________________________________________________________ 2. If the trademark owner is not the entity certifying, attach written authority of the trademark owner to use the trademark being certified. 3. Identify the fabricator, the entity that actually puts the cigarettes and/or roll-your-own into packages: Name and Address:___________________________________________________________________________ ___________________________________________________________________________________________ 4. Identify the entity that determines packaging design and printing for the brand(s)._______________________ ___________________________________________________________________________________________ 5. Provide packaging samples for all brand styles being certified for sale in the State of Wyoming. 6. Identify the entity that determines pricing for the brand(s)._________________________________________ ___________________________________________________________________________________________ 7. Identify the entity that determines the ingredients that go into the brand(s).____________________________ ___________________________________________________________________________________________ 8. Identify the entity that decides on marketing strategy for the brand(s).________________________________ ___________________________________________________________________________________________ 9. Identify the entity that pays for and provides the fabricator with facilities and equipment._________________ ____________________________________________________________________________________________ 10. Provide a photograph of the fabricator facilities. 11. Identify the entity that provides ingredients for the brand(s)._______________________________________ ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com State of Wyoming Non-Participating Manufacturer Certification Form - Attachment A - Page 2 12. Identify the entity that contracts with the fabricator to produce the brand, if the entity is other than the fabricator: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 13. Provide the identity and position of the person in whose name the ingredient list for the brand(s) and styles, is on file with the United States Department of Health and Human Services (HHS) as required by 15 USC § 1335a. ___________________________________________________________________________________________ 14. Provide a copy of the correspondence from HHS certifying each brand’s compliance with the provisions of 15 USC 1335a of the Federal Cigarette Labeling and Advertising Act (FCLAA). 15. Provide a copy of the correspondence from the FTC approving the rotation plan. 16. Identify the importer of the brand(s):__________________________________________________________ ___________________________________________________________________________________________ 17. Identify any exclusive import or distribution agreements that exist for the brand(s) in Wyoming.__________ ___________________________________________________________________________________________ 18. If the certifying company is foreign, provide a copy of the Articles of Incorporation and documentation that the company is in good standing with its governmental authorities. 19. Provide a list of affiliates, partners, and all officers of the certifying company.________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________________________ 20. If the certifying company is represented by counsel, please give the name and mailing address information, and authorization for counsel to deal directly with the Office of the Attorney General, Tobacco Settlement Unit. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 21. Identify who pays the FET on the brand._______________________________________________________ 22. Are the brands being certified in escrow payment default in any other state where the brands have been sold? If yes, give details. ____________________________________________________________________________________________ ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com