North Dakota > Statewide > Office Of State Tax Commissioner > Cigarette And Tobacco
Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - North Dakota
| Certificate Of Compliance Non-Participating Manufacturer Escrow Payment Form. This is a North Dakota form and can be used in Cigarette And Tobacco Office Of State Tax Commissioner Statewide . |
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North Dakota Office of State Tax Commissioner Certificate of Compliance Non-Participating Manufacturer Escrow Payment Manufacturer's Identification Name: Address: Phone: Fax: Sales Year The Year of Sales for this Certificate of Compliance is: (Complete a separate certificate for each year of sales) Units Sold Total number of individual cigarettes and "roll-your-own" tobacco sold by the Manufacturer identified above during the Brand Name: Brand Name: Brand Name: sales year is: Number of Cigarettes: Number of Cigarettes: Number of Cigarettes: Total Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Escrow Rates and Payments For the sales year: (Use and adjust the rates listed below to figure the appropriate total deposit amount) 2000 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0104712 2001-2002 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0136125 2003-2006 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0167539 2007 and thereafter - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0188482 Inflation Adjustment The appropriate deposit subtotal is $ . For payments due April 15, 2012, multiply the deposit subtotal by 49.92446% (.4992446 ) and enter the result. Escrow Deposit Paid The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for the sales year. $ (Add deposit subtotal and the inflation adjustment amount.) Note: For the initial deposit, attach a copy of your executed escrow agreement and for all deposits attach copies of your receipt or other proof of deposit from your financial institution and copies, if any, of amendments to your escrow agreement. Financial Institution Name of Institution: Address: Escrow Acct. No.: Sub-Acct. No.: Total Amount Held for the State 23506 (04/12) American LegalNet, Inc. www.FormsWorkFlow.com Signature Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this Certificate of Compliance is true and accurate. The Certificate of Compliance must also be signed and dated by an authorized notary Name of Authorized Agent: Signature of Authorized Agent: Subscribed and sworn to before me on this date: Signature of Notary Public: My Commission Expires: Title: Date: Mail this Certificate of Compliance to: Office of State Tax Commissioner Tobacco Tax Section 600 E. Boulevard Ave. Dept. 127 Bismarck ND 58505-0599 American LegalNet, Inc. www.FormsWorkFlow.com
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