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Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - South Dakota Office Of The Attorney General - 2011 Page 2

Part 7: Financial Institution

Name of Institution: ___________________________________________________________________________

Address: ____________________________________________________________________________________

Escrow Acct No: ________________________ sub-account No. for South Dakota: ________________________

Total Amt Held for South Dakota: _______________Total Balance in Escrow Account: _____________________

Copies of your receipt or other proof of deposit from your financial institution, must be

attached and filed with this Certificate of Compliance.

Part 8

: Signature

I hereby certify that the above-named manufacturer has deposited $0.0188482 for each unit sold (cigarette and "roll-

your-own" tobacco as defined by SDCL 10-50B-4) in South Dakota in Quarter 1 of year 2011, plus the estimated

inflation adjustment due, into the above-described escrow account. Under penalty of perjury, I state that, to the best

of my knowledge, all of the information contained in this Certificate of Compliance is true and accurate.

Name of Authorized Agent: _________________________________ Title: _______________________________

Signature of Authorized Agent: ___________________________________________ Date: ___________________

Subscribed to and sworn to before me, a Notary Public, on this ____ day of __________, _____.

_________________________________________________________

Notary Public

(SEAL)

My commission expires:

_________________________________

Mail this certificate of compliance to:

Office of the Attorney General

Attn: Donald E. Tinklepaugh

Assistant Attorney General

1302 E. Highway 14, Suite 1

Pierre, SD 57501-8501

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Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - South Dakota Office Of The Attorney General - 2011 Page 2