Certification Of No Sales By Non-Participating Manufacturer (Yearly Deposits-Cigarettes)

Rev. (01/17) Page 1 of 1 COMMONWEALTH OF VIRGINIA Certification of No Sales by Non-Participating Manufacturer (Yearly Deposits; Cigarettes) Part 1: Tobacco Product Manufacturer Identification Full Legal Name: Address: Contact: Phone: Fax: Email: Part 2: Date this certification was executed For Sales Year: (Complete a separate Certification for each Sales Year) Part 3: Brand Family(s): Part 4: Certification The Tobacco Product Manufacturer certifies that the company: (1) has elected not to become a participating manufacturer (as that term is defined in section II (jj) of the Master Settlement Agreement) and generally perform its financial obligations under the Master Settlement Agreement; and (2) has not sold any cigarettes in the Commonwealth of Virginia, whether directly or through a distributor, retailer or similar intermediary or intermediaries, during the Sales Year, as measured by excise taxes collected by the Commonwealth on cigarette packs bearing the excise tax (revenue) stamp of the Commonwealth. Part 5: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that the information contained in this Certification of No Sales is true, correct and complete, and that I am a qualified company officer authorized to bind the Tobacco Product Manufacturer filing this Certification of No Sales. Name: Title: Phone: Fax: Email: Date: Signature: Notary: City/County of Subscribed and sworn to before me on this date: Signature: My commission expires: The Certification of No Sales is due by April 30 of the year following the Sales Year. Mail fully executed Certification of No Sales to: Tobacco Section Office of the Attorney General 202 N. 9th Street Richmond, Virginia 23219 American LegalNet, Inc. www.FormsWorkFlow.com