Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification Page 3

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The company certifies that at the time of this certification, the company has:

Enclosed the completed Annual Escrow Compliance Certificate and Affidavit

(Form

5302) for the prior year’s sales in Missouri.

Established and continues to maintain a Qualified Escrow Fund as defined in

Section 196.1000(f),

RSMo, and said fund complies with

Section 196.1000

196.1003,

RSMo.

Executed a Qualified Escrow Agreement that has been reviewed and approved by the Director of Revenue for the state of Missouri and

that governs the Qualified Escrow Fund for the state of Missouri. A copy of the current Qualified Escrow agreement, including any

amendments, is attached.

Ensured that the escrow funds held in the Qualified Escrow Fund on behalf of the state of Missouri are in a separate segregated

account, separate and apart from escrow funds held on behalf of any other beneficiary.

Attached information documenting all deposits and withdrawals from the Qualified Escrow Fund during the last year and attached

proof of current escrow account balance from the Escrow Agent.

Name of Financial Institution

Telephone Number

(

)

___ ___ ___

___ ___ ___ ___

Contact Person Name

Fax Number

(

)

___ ___ ___

___ ___ ___ ___

Mailing Address

City

State

Zip Code

Escrow Account Number

Missouri Sub-Account Number

The company (select one):

Is registered to do business in the state of Missouri; or

Has approved a resident for service of process in the state of Missouri and provided notice to the Director of Revenue for the state of

Missouri by submitting a completed Non-Participating Manufacturer’s Appointment of Registered Agent

(Form

5300) for the state of Missouri

and Registered Agent’s Statement

(Form

5299), which can be found at

Yes

Select Yes or No as appropriate to all questions. Provide additional information where requested.

List all prior manufacturers of any brand listed in this certification.

Has any state obtained a court judgement or administrative order against company relating to brand families listed on

this certificate? If yes, list the location, case number, and date of the judgment or order and the brand families involved.

As of the date of this certification, has the company satisfied all court judgments and orders to pay penalties, related to brand

families in this certification?

Has your company ever been investigated or contacted by a law enforcement agency concerning a violation of law

relating to the brand families you manufacture or have manufactured? If yes, please indicate what law enforcement

agency contacted or investigated your company and the Brand Families involved.

Has any state de-listed from its tobacco directory or refused to list on its tobacco directory your company or any brand

families listed on this certificate? If yes, identify each such state, describe the circumstances, and attach the letter,

e-mail or other document indicating the refusal to list or decision to de-list.

Under penalty of perjury, I certify and declare that all of the statements contained in this certification, including but not limited to any accompanying

statements or attachments herewith, are true, correct, accurate and complete in every particular, and that I am a person authorized to bind the

Tobacco Product Manufacturer making this Certification either under the laws of the state of Missouri or the jurisdiction where the manufacturer

resides or is organized. Any violation of the requirements of

Sections 196.1003

and

196.1020

196.1035,

RSMo, is basis for removal of the

company’s brands from Missouri’s Directory of Compliant Tobacco Products Manufacturers.

Signature of Authorized Person

Date (MM/DD/YYYY)

___ ___