Licensed Wholesaler Quarterly Report

STATE OF ARKANSAS - TOBACCO PRODUCTS MANUFACTURER CERTIFICATION FORM 201 * Due On or Before April 30, 201 TYPE OF CERTIFICATION: PART 1: TOBACCO PRODUCT MANUFACTURER IDENTIFICATION BUSINESS INFORMATION: IS THE COMPANY REPRESENTED BY COUNSEL? IDENTIFICATION OF COUNSEL: PART 2: DESIGNATION OF TOBACCO PRODUCT MANUFACTURER AS OF THE DATE OF CERTIFICATION, THE COMPANY IS A: PART 3: BRAND FAMILY IDENTIFICATION PMs must complete column 1. NPMs must complete columns 1 and 2. 1.Brand Family: 2.Units Sold During Sales Period Total Number of Units Sold: American LegalNet, Inc. www.FormsWorkFlow.com By including a brand family in this Certification Form, a Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of calculating its payments under the Master Settlement Agreement. By including a brand family in this Certification Form, a Non-Participating Manufacturer affirms that the brand family is deemed to be its cigarettes for purposes of escrow. Despite this, the Office of the Arkansas Attorney General retains the discretion to determine that the listed brand family is the product of another tobacco product manufacturer. PACKAGING OR LABELING: FIRE-SAFE COMPLIANCE: et seq.? DEPARTMENT OF HEALTH AND HUMAN SERVICES INGREDIENT LIST: FEDERAL TRADE COMMISSION ROTATION PLAN: TOTAL NATIONWIDE SALES ON WHICH FEDERAL EXCISE TAX WAS PAID: In the case of a domestic tobacco product manufacturer, copies of Tobacco Tax Bureau Form 5210.5 supporting the total sales number must be included with this Certification Form. In the case of a foreign tobacco product manufacturer, a copy of Tobacco Tax Bureau Form 5220.6 supporting the total sales number must be included. TOTAL NATIONWIDE SALES REPORTED PURSUANT TO 15 U.S.C. 247 376: Copies of all reports made pursuant to 15 U.S.C. 247 376 must be included with this Certification Form. The company submitting this form must submit reports to states other than Arkansas. : American LegalNet, Inc. www.FormsWorkFlow.com PART 4: BUSINESS AND OWNERSHIP INFORMATION A. Participating and Non-Participating Tobacco Product Manufacturers FABRICATION OF BRAND FAMILIES: MANUFACTURING FACILITY IDENTIFICATION: MANUFACTURER EQUIPMENT IDENTIFICATION: ACCESS TO MANUFACTURING FACILITY AND EQUIPMENT: American LegalNet, Inc. www.FormsWorkFlow.com PHOTOGRAPH OR DIAGRAM OF INTERIOR OF MANUFACTURING FACILITIES: PHOTOGRAPH OF EXTERIOR OF MANUFACTURING FACILITIES: PROOF OF OWNERSHIP OF MANUFACTURING FACILITIES: PROOF OF OWNERSHIP OF MANUFACTURING EQUIPMENT: U.S. DEPARTMENT OF TREASURY, TOBACCO TAX BUREAU PERMIT NUMBER: A copy of the permit issued by the U.S. Department of Treasury, Tobacco Tax Bureau must be included with this certification form. IDENTIFICATION OF WHOLESALERS, DISTRIBUTORS, OR STAMPING AGENTS TO WHOM CIGARETTES WERE SOLD FOR DISTRIBUTION IN THE STATE OF ARKANSAS: CRIMINAL ACTIVITY: American LegalNet, Inc. www.FormsWorkFlow.com INDICTMENT: ADVERTISING PRACTICES: JENKINS ACT COMPLIANCE: et seq. DIRECTORY STATUS: American LegalNet, Inc. www.FormsWorkFlow.com B. Non-Participating Manufacturers Only IDENTIFICATION OF DIRECTORS, MEMBERS, OFFICERS, AND OWNERS OF THE COMPANY: ASSOCIATION WITH OTHER TOBACCO PRODUCT MANUFACTURERS: RECLASSIFICATION OF PRODUCTS AS CIGARETTES OR ROLL-YOUR-OWN: American LegalNet, Inc. www.FormsWorkFlow.com PART 5: NON-PARTICIPATING MANUFACTURER CERTIFICATION NON-PARTICIPATING MANUFACTURER222S REGISTERED AGENT FOR SERVICE OF PROCESS: A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form. Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas. CONSENT TO BE SUED: A properly executed copy of the Consent to be Sued form must be included with this Certification Form. ACCEPTANCE OF JOINT-AND-SEVERAL LIABILITY BY IMPORTERS: A properly executed copy of the Acceptance of Joint-and-Several Liability by Importers form must be included with this Certification Form. IMPORTER222S REGISTERED AGENT FOR SERVICE OF PROCESS: A statement from the Registered Agent noting his or her service in this capacity must be included with this Certification Form. Pursuant to Arkansas law, this Registered Agent must reside in the State of Arkansas. BONDING: If your answer to the preceding question was 223yes,224 a copy of such bond must be included with this Certification Form. QUALIFIED ESCROW ACCOUNT: A copy of the current governing Escrow Agreement and any Amendments thereto must be included with this Certification Form. American LegalNet, Inc. www.FormsWorkFlow.com ESCROW OBLIGATION FOR SALES PERIOD: $0.0 Amount Deposited for Sales Year: An account statement or letter from the escrow agent must be included with this Certification Form. This account statement or letter must indicate: (1) the amount deposited, as indicated above and (2) the date of deposit. The inflation adjustment used herein may not be accurate for Quarterly Certifications; the total amount to be deposited into the Qualified Escrow may need to be recalculated at the time of the Annual Certification. TOTAL AMOUNT HELD IN ESCROW FOR ARKANSAS: all DEPOSITS AND WITHDRAWALS DURING SALES PERIOD: Totals: An account statement from the escrow agent must be included with this Certification Form, indicating the complete account history for the account/sub-account for the State of Arkansas for all sale years, including all deposits, withdrawals, interest earned, and a current account balance. PART 6: SIGNATURE The knowing submission of false or inaccurate information to the Office of the Arkansas Attorney General could result in a civil penalty being issued against you in an amount up to $10,000.00. PART 7: NOTARY Seal of Notary must be included and should overlap the right-hand column of the above box. American LegalNet, Inc. www.FormsWorkFlow.com PART 8: CHECKLIST AND MAILING PRIOR TO MAILING, PLEASE ASSURE THAT THE FOLLOWING HAS BEEN PROVIDED: IN THE CASE OF A NON-PARTICIPATING MANUFACTURER, PLEASE ALSO ASSURE THAT THE FOLLOWING HAS BEEN PROVIDED: MAIL THE COMPLETED CERTIFICATION FORM TO: Certification Forms, including attachments, must be received on or before . Certification Forms will processed unless all fields are completed and all required attachments have been received. American LegalNet, Inc. www.FormsWorkFlow.com