Certification Of Tobacco Product Manufacturer That Signed Master Settlement Agreement

State of West Virginia Certification of Tobacco Product Manufacturer That Signed Master Settlement Agreement (Pursuant to WV Code § 16-9D-3) Part 1: Tobacco Product Manufacturer Identification Tobacco Company Manufacturer Information Company Name: Street Address: City: State/Country: Postal Code: Telephone: Fax: Email: Name/Title of Person Completing Report: Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 2: Brand Family Identification (attach additional sheets if necessary) The Participating Manufacturer identified in Part 1 has the following Brand Families, each of which the manufacturer hereby affirms are to be deemed its Cigarettes for purposes of calculating its payments under the Master Settlement Agreement for the relevant year, in the volume and shares determined pursuant to the Master Settlement Agreement. Brand Families (List Below) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 3: Execution by Authorized Designee Under penalty of perjury, I state that the information contained in this Certification is true and accurate. Designee (Print Name): Title: Mailing Address: Telephone: Email: Signature of Designee: Date: Subscribed and sworn to before me on this date: City or County of My Commission expires: Signature of Notary Public: Mail the completed certificate of compliance to: Tobacco Litigation Unit The Office of the Attorney State Capitol Complex Building 1, Room W-435 Charleston, WV 25305 and West Virginia State Tax Department General Excise Tax Unit P.O. Box 2991 Charleston, WV 25330-2991 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com