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

Download a blank fillable Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5304 - Missouri Tobacco Directory - Non-Participating Manufacturer Certification with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

PART 9: QUALIFIED ESCROW FUND AND FINANCIAL INSTITUTION

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

Enclosed the completed Form 5302 Annual Escrow Compliance Certificate and Affidavit 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 to

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:

Escrow Account Number:

Missouri Sub-Acct. Number:

PART 10: REGISTERED AGENT/APPROVED AGENT FOR SERVICE OF PROCESS

The company (check 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 Form 5300 Non-Participating Manufacturer’s Appointment of Registered Agent for the state of Missouri and Form 5299

Registered Agent’s Statement, which can be found at

PART 11: DISCLOSURES

YES

Check YES or NO as appropriate to all questions. Provide additional information where requested.

Within the past two (2) years, has there been a change in manufacturer (fabricator) of one or more of the brand families listed

in this certification? If yes, provide details of change.

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 and attach the letter, e-mail or other document indicating the refusal

to list or decision to de-list.

PART 12: EXECUTION BY AUTHORIZED PERSON

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 attach-

ments 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 to 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:

Printed Name:

Title:

Mail the completed original Participating Manufacturer’s certification and all supporting documents to:

MISSOURI ATTORNEY GENERAL

MISSOURI DEPARTMENT OF REVENUE

And

Taxation Division

P.O. Box 899

207 W. High

P.O. Box 811