Arkansas > Statewide > Attorney General > Tobacco
Non-Participating Manufacturer Quarterly Certification Form - Arkansas
| Non-Participating Manufacturer Quarterly Certification Form Form. This is a Arkansas form and can be used in Tobacco Attorney General Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
NON-PARTICIPATING MANUFACTURER QUARTERLY CERTIFICATION FORM CERTIFICATION TYPE: Original REPORTING PERIOD: First Quarter BUSINESS INFORMATION: Business Name: Address: State: Telephone: BRAND SALES: Brand Family: STATE OF ARKANSAS CERTIFICATION YEAR 2012 *Due Within 20 Days of Conclusion of Each Calendar Quarter Amended Second Quarter Third Quarter Fourth Quarter Contact Person: City: Zip Code: Email: Units Sold During Calendar Quarter: Total Number of Units Sold: To determine the number of units sold for roll-your-own tobacco products, divide the total number of ounces of each brand family by .09. For example, 18 ounces of roll-your-own is 200 units sold (18 ÷ .09 = 200). QUALIFIED ESCROW ACCOUNT: Financial Institution: Address: State: Email: Arkansas Sub-Account Number: Representative's Name: City: Zip Code: Escrow Account Number: Date of Escrow Agreement: ESCROW OBLIGATION FOR SALES PERIOD: Total number of units sold in Arkansas during calendar quarter: Statutory rate per cigarette ($0.0188482), as adjusted for inflation: Multiply units sold by the adjusted statutory rate per cigarette: Amount Deposited for Calendar Quarter: $0.0282581 An account statement or letter from the escrow agent must be included with this Certification Form. This account statement or letter must indicate: (1) the amount deposited, as indicated above and (2) the date of deposit. The total amount to be deposited into the Qualified Escrow may need to be recalculated at the time of the Annual Certification. American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL INFORMATION: Is the registered agent identified on the company's most recent Annual Certification still the registered agent for the NPM? Is the escrow agreement provided with the company's most recent Annual Certification still accurate, in force, and unchanged? If you answer to either of the preceding questions was "no," please explain. Explanation: Yes Yes No No TOTAL NUMBER OF CIGARETTES ON WHICH FEDERAL EXCISE TAX WAS PAID DURING CALENDAR QUARTER: Copies of Tobacco Tax Bureau Form 5210.5 supporting the total Federal Excise Tax paid must be included with this Certification Form. TOTAL NATIONWIDE SALES REPORTED PURSUANT TO 15 U.S.C. § 376: Copies of all reports made pursuant to 15 U.S.C. § 376 must be included with this Certification Form. The company submitting this form must submit reports to states other than Arkansas. SIGNATURE: Authorized Designee: Designee Signature: NOTARY: Subscribed and Sworn Before Me on this Date: Signature of Notary Public: City or County of: My Commission Expires: Title: Date: MAIL THE COMPLETED CERTIFICATION FORM TO: Office of the Arkansas Attorney General Certification Forms, including attachments, must be received within 20 days ATTN: Tobacco Division of the conclusion of each calendar quarter. Certification Forms will be returned and left unprocessed unless all fields are 323 Center Street, Suite 200 completed and all required attachments have been received. Little Rock, Arkansas 72201 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
