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Annual Escrow Compliance Certificate And Affidavit (Non-Participating Manufacturers) 5302 - Missouri
| Annual Escrow Compliance Certificate And Affidavit (Non-Participating Manufacturers) Form. This is a Missouri form and can be used in Department Of Revenue Statewide . |
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ANNUAL ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (NON-PARTICIPATING MANUFACTURERS) PART 1: SALES YEAR SALES YEAR _________________ Missouri Department of Revenue Taxation Division P.O. BOX 811 Jefferson City MO 65105-0811 FORM 5302 (REV. 01-2013) PART 2: MANUFACTURER IDENTIFICATION COMPANY NAME MAILING ADDRESS CITY PHYSICAL ADDRESS STATE ZIP CODE COUNTRY FEDERAL I.D. NUMBER __ __ __ __ __ __ __ __ __ __ __ __ __ __ CITY STATE ZIP CODE COUNTRY __ __ __ __ __ TELEPHONE NUMBER __ __ __ __ __ __ __ __ __ __ __ __ __ __ FAX NUMBER __ __ __ __ __ __ __ __ __ __ __ __ __ __ E-MAIL ADDRESS PART 3: UNITS SOLD (THE NUMBER OF INDIVIDUAL CIGARETTES SOLD IN THE STATE OR OUNCES OF RYO DIVIDED BY .09) ((( BRAND FAMILY (Do not separately list styles within a brand family such as Regular, Menthol, Light, 100s, etc.)* CIGARETTES (C) or RYO (RYO) NUMBER OF UNITS (STICKS) SOLD DURING THE SALES YEAR (FOR RYO, STICKS = OUNCES รท .O9) TOTAL UNITS SOLD: *By including a brand family in its certification, a Non-Participating Manufacturer affirms that the brand family listed is deemed to be its cigarettes for escrow purposes for the year indicated in Part 1 of this form. However, the Director of Revenue retains the discretion to determine whether the brand family constitutes the cigarettes of another tobacco product manufacturer. Page 1 of 2 DOR-5302 (01-2013) American LegalNet, Inc. www.FormsWorkFlow.com PART 4: CALCULATION OF ESCROW DEPOSIT AMOUNT USE THE RATES BELOW TO FIGURE THE APPROPRIATE DEPOSIT AMOUNT. ESCROW DUE/SALES YEAR: $.0094241 per unit sold after July 1, 1999 (effective date of the Act) plus inflation of 3%; For 2000: $.0104712 plus inflation of 6.48841% per unit sold: For 2001: $.0136125 plus inflation of 9.68306% per unit sold: For 2002: $.0136125 plus inflation of 12.97355% per unit sold: For 2003: $.0167539 plus inflation of 16.36276% per unit sold: For 2004: $.0167539 plus inflation of 20.15102% per unit sold: For 2005: $.0167539 plus inflation of 24.25497% per unit sold: For 2006: $.0167539 plus inflation of 27.98262% per unit sold: For 2007: $.0188482 plus inflation of 33.20594% per unit sold: For 2008: $.0188482 plus inflation of 37.20212% per unit sold: For 2009: $.0188482 plus inflation of 41.31818% per unit sold: For 2010: $.0188482 plus inflation of 45.55773% per unit sold: For 2011: $.0188482 plus inflation of 49.92446% per unit sold: For 2012: $.0188482 plus inflation of 54.42219% per unit sold for a total of $.0291058 per unit sold. Number of Units (Sticks) Sold : Escrow Deposit for State of Missouri: Escrow Deposit Date(MM/DD/YYYY): ___________________ $ ___________________ Units Sold times the appropriate rate above: $ ___________________ _ _ / _ _ / __ __ __ __ PART 5: FINANCIAL INSTITUTION FINANCIAL INSTITUTION AUTHORIZED CONTACT NAME AND TITLE ADDRESS CITY TELEPHONE NUMBER E-MAIL ADDRESS TOTAL FUNDS HELD IN SEPARATE ACCOUNT FOR MISSOURI STATE FAX NUMBER ZIP CODE __ __ __ __ __ (__ __ __) __ __ __ - __ __ __ __ (__ __ __) __ __ __ - __ __ __ __ PRIMARY ESCROW ACCOUNT NUMBER MISSOURI SUB-ACCOUNT NUMBER(S) DATE OF LAST AMENDMENT TO ESCROW AGREEMENT (MM/DD/YYYY) $ DATE ESCROW WAS ESTABLISHED (MM/DD/YYYY) __ __ / __ __ / __ __ __ __ __ __ / __ __ / __ __ __ __ Attached is a copy of the financial institution's receipt or other proof of deposit of the proper escrow payment. Attached is an executed copy of the Escrow Agreement with all amendments and attachments. Under penalty of perjury, I declare that I am authorized to certify on behalf of the Tobacco Manufacturer in Part 2 that all of the information contained in this Escrow Compliance Certificate, including but not limited to any accompanying statements or attachments herewith, are true, accurate and complete in every partiulcar, and that I am a person authorized PART 6: SIGNATURE 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 section 196.1003 and 196.1020 and 196.1020 to 196.1035, RSMo, is basis for removal of the company's brands from Missouri's Directory of Compliant Tobacco Manufacturers. NAME (PRINT) TITLE SIGNATURE DATE(MM/DD/YYYY) PART 6: SIGNATURE __ __ / __ __ / __ __ __ __ Mail the completed certificate of compliance to: Missouri Department of Revenue Taxation Division P.O. Box 811 301 W. High Street, Room 330 Jefferson City, MO 65105-0811 573-751-7163 Missouri Attorney General P.O. Box 899 207 W. High Jefferson City, MO 65102 573-751-3321 Page 2 of 2 DOR-5302 (01-2013) American LegalNet, Inc. www.FormsWorkFlow.com And
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