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Certificate of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment - Washington
| Certificate of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Form. This is a Washington form and can be used in Tobacco Suppliers And Manufacturers Office Of The Attorney General Statewide . |
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DUE April 15, July 15, October 15, 2012 and January 15, 2013 for Liability Year 2012. Washington Certificate of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Part 1: Manufacturer's identification 1. 2. 3. 4. 5. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ Telephone number: ___________________________________________________________________________________________ Electronic mail address:________________________________________________________________________________________ Part 2: Liability quarter/year Complete only one year of liability on this form. 6. The liability quarter/year for this certificate is: __________________________ Part 3: Units sold 7. Number of individual cigarettes and roll-your own sold by the manufacturer identified above during the liability year bearing Washington cigarette tax stamps is as follows: Part 7__________________________ 4: Deposit amount For Liability Year 2007 and thereafter, the rate per cigarette is 0.0188482. *8. Multiply Line 7 by 0.0291058 (2012 combined base rate and estimated annual inflation rate) and enter the amount in line 8: Total Quarterly Escrow Paid Note: Attach a copy of your receipt or other proof of deposit from your financial institution. 8__________________________ Part 5: Financial institution 9. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ 10. Escrow account number _____________________________ Total amount held in this account $_____________________________ Part 6: Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. ______________________________________________________ Print the name of authorized agent Title _______________________________________________________ Signature of authorized agent Date City / State: ______________________________________________ Subscribed and sworn to before me this ________ day of ___________________, 2012. _________________________________________________ Signature of Notary Public My commission expires ________/__________/__________ * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. The form should be sent to either the following mailing address or if by courier, to our delivery address: Attorney General's Office Revenue Division PO Box 40123 Olympia, WA 98504-0123 Attorney General's Office Revenue Division 7141 Cleanwater Drive SW Tumwater, WA 9850 American LegalNet, Inc. www.FormsWorkFlow.com OR
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