Non-Participating Tobacco Product Manufacturer Certificate Of Compliance

Page 1 of STATE OF OHIO NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER CERTIFICATE OF COMPLIANCE Pursuant to R.C. 1346.02 and 1346.05 and Ohio Adm.Code 109:8-1-01 thru 109:8-1-03 PART 1: NON-PARTICIPATING TOBACCO PRODUCT MANUFACTURER IDENTIFICATION Company Name TTB Permit Number Address P.O. Box City/State/Zip/Country Telephone NumberFax Number E-Mail Address Website URL Name/Title of Person Completing Form B.This form is (check one below): Annual Certification Due A April 30, 201 for Ohio sales in 201 InitialManufacturer is not currently listed on the Ohio Tobacco Directory Supplemental Certification Change of information provided to the Attorney General PART 2: NON-PARTICIPATING MANUFACTURER BRAND FAMILY IDENTIFICATION The Tobacco Product Manufacturer seeks to certify the following brand families and accepts escrow responsibility for all cigarettes and RYO sold in Ohio under these brand names. A.List the brands which are being sold by the manufacturer identified in Part 1A and are currently listed on the Ohio Tobacco Directory. Brand Name CigaretteRYOBrand NameCigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO B.List any new brands that are not currently listed on the Ohio Tobacco Directory which the manufacturer, identified in Part 1A, intends to sell in OhioBrand Name Cigarette RYO Brand Name Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO C.Identify any brands currently listed on the Ohio Tobacco Directory that are no longer being sold bythe manufacturer Brand Name Cigarette RYO Brand Name Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Click to Extend Tables Page 2 of PART 3: REQUIRED INFORMATION For each brand certified in Parts 2A and 2B of this Certificate of Compliance, complete a Brand IdentificationForm NPM002 (Rev. 03/201 . copy of the current U.S. Treasury Tobacco Tax Bureau (TTB) permit as a manufacturer and/orimporter as required by 26 U.S.C. §5712 and §5713 must be provided for the tobacco productmanufacturer identified in Part 1A of this form. To ensure compliance with Ohio Adm.Code 109:8-1-02(A)(5), provide a Statement of Condition from theOhio Department of Taxation D. If not previously submitted, or if changed since last submission, provide original packaging for o one brand style which is representative of each brand family certified in Parts 2A and 2B of this form. Flat empty cartons and packs are preferred. Submit new packaging each time you change your packaging or add newbrand families. C Check one below: Packaging for each brand family has not been previously submitted/has changed. Samples are enclosed. Packaging for each brand family has been previously submitted and has not changed PART 4: ADDITIONAL INFORMATION A. Pursuant to R.C. 3739.07, a manufacturer must submit to the State of Ohio Fire Marshal a certification thatits brands meet the requirements of the Reduced Ignition Propensity Standards for Cigarettes. P Please checkbelow: Each brand family listed in Part 2A and 2B meets the requirements of the Reduced Ignition Propensity Standards for Cigarettes in Ohio. B. Pursuant to the federal Prevent All Cigarette Trafficking (?PACT?) Act, 15 U.S.C. §§375, et.seq., all personswho sell, transfer, or ship cigarettes (including roll-your-own tobacco) in interstate commerce for profit, orwho offers cigarettes for such a sale, transfer, or shipment must: (1) register with the tobacco taxadministrator of the state into which shipment is made; and (2) file monthly reports with the tobacco taxadministrator (Ohio Department of Taxation), no later than the 10th of each month, identifying the brands,quantities, and recipients of cigarette shipments into such state. P Please check below The Tobacco Product Manufacturer listed in Part 1A is in full compliance with the PACT Act, including but not limited to: registering and filing monthly reports with the Ohio Department of Taxation. C. Pursuant to R.C. 2927.023 the shipment of cigarettes to anyone in Ohio other than ?authorized recipients?of tobacco products, as that term is defined in R.C. 2927.023(A)(1), is strictly prohibited. Ohio law requiresthat all direct cigarette sales to Ohio consumers be made in a ?face?toface? transaction. Thus, cigarettescannot be sold via the Internet to Ohio consumers. P Please check below: The Tobacco Product Manufacturer listed in Part 1A is in full compliance of R.C. 2927.023. Attach TTB Permit Click Here to Request a Statement of Condition *Please note - the link takes you to the Ohio Department of Taxation website - the request must be submitted, per instructions, to the Ohio Department of Taxation. Attach Statement of Condition Attach R.I.P.C. Certification Page 3 of PART 5: NON-PARTICIPATING MANUFACTURER REGISTERED AGENT Check one below: The non-participating manufacturer identified in Part 1A is registered to do business in Ohio. The non-participating manufacturer identified in Part 1A has appointed and continues to engage the following agent located in Ohio. A current letter (dated this year) from the registered agent accepting this appointment must be attached. Name of Registered Agent Address City State Zip Telephone NumberFax Number PART 6: NON-PARTICIPATING MANUFACTURER QUALIFIED ESCROW ACCOUNT A.Escrow Account Information The non-participating manufacturer identified in Part 1A has established and continues to maintain the followingqualified escrow fund under R.C. 1346.02.Name of Financial Institution Address City State Zip Country Contact Name/Title Telephone Number Fax Number Escrow Account Number Ohio Sub-Account Number Provide name of any security interest in escrow account The following are part of the Certification and must be sent to the Ohio Attorney General's Office d directly fromthe named financial institution. The Financial Institution noted in Part A of this certification is required toprovide the following and are due by April 30, 201: An executed copy of the Non-Participating Manufacturer?s current Escrow Agreement, along with anyamendments or attachments.Proof of amount and date of deposit to Ohio?s segregated sub-account for 201 sales.Current account ledger of the tobacco product manufacturer?s segregated sub-account for Ohio.Provide the name of any security interest in the escrow account. If there is no security interest, thefinancial institution must provide verification that there is none. Escrow calculation and deposit for sales in Ohio in 201.1. Show on Line A, the total units sold by the non-participating manufacturerin Ohio during calendar year 201: A. 2. On Line B, the applicable rate per unit sold in 201 is the base rate per unit sold,$0.0188482, plus the inflation adjustment of 0. per unit. B. 3. Multiply Line A and B to determine the escrow deposit for 201 sales in Ohio: C . DEPOSIT TO OHIO SEGREGATED SUB-ACCOUNT MUST BE MADE BY APRIL 15, 201 Attach Registered Agent Letter 0.0347539$0.00Page 4 of Form NPM001 (Rev. 03/201) D.Quarterly Escrow Deposits Previously Made for 201Sales. Date of DepositAmount of Deposit 1st Quarter Deposit 1st Quarter Additional Deposit 2nd Quarter Deposit 2nd Quarter Additional Deposit 3rd Quarter Deposit 3rd Quarter Additional Deposit 4th Quarter Deposit 4th Quarter Additional Deposit Total Deposit E.Additional Escrow Deposit/Withdrawal History for the State of Ohio: ( (Attach additional sheets if necessary)Withdrawals must comply with R.C. 1346.02 and verification of compliance must be provided. DateDepositWithdrawalBalance Total:Total:Total: PART 7: ESCROW INVESTMENT INFORMATION (Attach Separate Response) 1.In order to be compliant with Section 5 of the Escrow Agreement entered into between the NPMand the Escrow Agent, both the aggregate federal tax cost and the aggregate face value of thecash investments held in the account must equal or exceed the accumulated required deposits.Please confirm that all cash and investments in the qualified escrow fund held for the benefit ofthe State of Ohio are complaint with Section 5 of the Escrow Agreement. Please also provide adetailed accounting regarding each investment, including wheth