Form Dr 0231 - Tobacco Product Manufacturer Certification (Page 10 of 10) in pdf

3. Convictions

Has Applicant or any other Person or Affiliate of Applicant been convicted of a crime under federal, state, or foreign laws

in connection with the sale of cigarettes? For every such conviction, list:

a. the name of the Applicant, Person, or Affiliate convicted;

b. the governmental entity (federal, state, local, or foreign) that prosecuted Applicant, Person, or Affiliate;

c. the case number;

d. the name and address of the government entity that prosecuted Applicant, Person, or Affiliate.

Yes, the details of each occurrence are attached to this Certification.

Not applicable

4. Denial of Listing

Has the Applicant or any other Person or Affiliate of Applicant been denied listing on any state directory, which is similar

to the subject of this Certification? For every such denial, list:

a. the name of the Applicant, Person, or Affiliate denied listing on a state directory;

b. the Tobacco Product Manufacturer and/or Brand Family(ies) denied listing; and

c. the State which denied listing

Yes, the details of each occurrence are attached to this Certification.

Not applicable

5. Compliance with the provision of C.R.S. § § 39-28-201 through 39-28-307

Has any Person involved with Applicant (owner, officer, director, employee) been involved as an officer, director,

or owner of any other tobacco company or Affiliate which has not made its escrow deposits as Non-Participating

Manufacturer under any state escrow statute? For every such occurrence, list:

a. the name of the Applicant, Person, or Affiliate which has not satisfied its NPM escrow obligations;

b. the Brand Family(ies) for which there was a failure to comply; and

c. the amounts of any escrow deposits that are still owed.

Yes, the details of each occurrence are attached to this Certification.

Not applicable

Part 6—Signature

Under penalty of perjury, I declare that to the best of my knowledge, the information contained in this Certification is true

and accurate.

Authorized Designee

Title

Signature of Authority

Date

Subscribed and sworn to before me on this date

Signature of Notary Public

City of

County of

My Commission expires

Mail a completed Certificate of Compliance to each office listed below:

Colorado Department of Revenue

Colorado Department of Law

Excise Tax Accounting Section, Room 237

Tobacco Settlement Enforcement

PO Box 17087

Ralph L. Carr Colorado Judicial Center

Denver CO 80217-0087

1300 Broadway, 7th Floor

303-205-8211, Ext. 6848

Denver CO 80203

(720) 508-6000 Main

Note: The state of Colorado will not process incomplete or illegible certifications.

Attach additional sheets as necessary to provide a complete response.

Form Dr 0231 - Tobacco Product Manufacturer Certification Page 10

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