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Rev. (03/19) Page 1 of 2 COMMONWEALTH OF VIRGINIA Compliance Certification by Non-Participating Manufacturer (Yearly Escrow Deposit Made in 2019 for 2018 RYO Tobacco Sales) Part 1: Tobacco Product Manufacturer Identification Full Legal Name: Address: Contact: Phone: Fax: Email: Part 2: Sales Year: 2018 Part 3: Units Sold (One Unit Sold Equals .09 ounces of RYO tobacco subjected to excise tax in Virginia). Step 1: Number of ounces of RYO tobacco product sold in the Commonwealth of Virginia, whether directly or through a distributor, retailer or similar intermediary or intermediaries, during the Sales Year, as measured by excise taxes collected by the Commonwealth on RYO tobacco. Number of Ounces Step 2: Calculate units sold: (Number of ounces 367 0.09) Units Sold Brand Family(s): Part 4: Escrow Rates and Deposit Amounts The escrow rate for RYO tobacco units sold in 2018, including the inflation adjustment, is .................................. $0.0347539. Total Deposit Due: $ (Units Sold x $0.0347539) Total Deposit Due Note: If Manufacturer is also depositing escrow based on cigarette sales, add the total RYO tobacco deposit from above to the amount to the cigarette escrow total as indicated on Compliance Certification for Cigarette Sales, and make one combined deposit, for cigarettes and RYO tobacco, to the escrow account. Proof of deposit in the form of statement of account from Financial Institution and anyamendments to the qualified escrow agreement must be attached to this ComplianceCertification. American LegalNet, Inc. Rev. (03/19) Page 2 of 2 Part 5: Financial Institution for Qualified Escrow Fund Agent: Institution: Address: Phone: Fax: Email: Escrow Account: Commonwealth of Virginia (Sub)Account: Cumulative Deposit Amount (all Sales Years) for sales in Virginia: $ Part 6: Affidavit of Tobacco Product Manufacturer (must be executed by an authorized officer) Under penalty of perjury, I state that the information contained in this Compliance Certification is true, correct and complete, and that I am a qualified company officer authorized to bind the Tobacco Product Manufacturer filing this Certification. Name: Title: Phone: Fax: Email: Date: Signature: Notary: City/County of Subscribed and sworn to before me on this date: Signature: My commission expires: The Compliance Certification is due by April 30 of the year following the Sales Year. Mail fully executed Compliance Certification to: Tobacco Enforcement Unit Office of the Attorney General 202 N. 9th Street Richmond, Virginia 23219 American LegalNet, Inc.