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Affidavit Of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment NPM-Q - Illinois
| Affidavit Of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Form. This is a Illinois form and can be used in Tobacco Enforcement Bureau Office Of The Attorney General Statewide . |
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State of Illinois Affidavit of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Please Review Instructions Prior to Completion. NPM-Q p. 1 of 3 Part 1: Liability Reporting Period The liability period for this affidavit is: (check one) 2013 Type of affidavit: (check one) Jan.-Mar. Due Apr. 30 Apr.-Jun. Due Jul. 31 Jul.-Sep. Due Oct. 31 Oct.-Dec. Due Jan. 31 Amended Original Part 2: Manufacturer Identification Company Name Mailing Address City Phone State Fax Zip Code Web Address Country FEIN Name and title of person completing this form Part 3: Brand Sales Brand Family (Attach Brands Addendum pages as necessary) Report Units Sold in Sticks for Cigarettes or in Ounces for RYO Check One Sticks Sold for this period Ounces Sold for this period Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Total Sold sticks ounces American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Affidavit of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Part 4: Certification of Escrow Account and Agreement NPM-Q p. 2 of 3 The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account, pursuant to Section 15 of the Escrow Act. Name of Financial Institution (Escrow Agent) Mailing Address City Phone Contact Person Escrow Account Number Illinois Sub-Account Number State Fax Contact E-Mail Total amount held in this account for the State of Illinois Zip Code $ Part 5: Worksheet for Cigarettes Sold During Liability Reporting Period Total of RYO Ounces from Part 3 RYO Stick Calculation (Divide RYO Ounces by .09) Total of Cigarette Sticks from Part 3 Total NPM Sales (Add RYO Stick Calculation to Total of Cigarette Sticks) Refer to Worksheet at left to calculate the number of individual cigarettes bearing Illinois cigarette tax stamps, including roll-your-own tobacco (.09 ounces = 1 cigarette), which were manufactured by this manufacturer and sold in Illinois during this reporting period. Liability Year Worksheet is for: 2013 Other: _____________ Please convert pounds to ounces before using this worksheet. (Multiply by 16.) Use the rates listed below to figure the appropriate deposit amount. Part 6: Deposit Amount For the liability year 2007 and later, the rate per cigarette is . . . . . . . . . . . .0188482 Contact the Tobacco Enforcement Bureau for rates for previous years. 1 2 3 Enter the appropriate rate for the reporting period. Multiply Line 1 by Total NPM Sales (Part 5) and write the amount. Multiply Line 2 by the inflation adjustment percentage and write the amount. For the 2013 liability year, use a preliminary inflation adjustment percentage of 54.42219 percent (multiplier of .5442219), based upon the 2012 inflation adjustment. 4 5 6 Enter the total amount to be paid into the escrow account for this period by the manufacturer identified in Part 2 (the total of Lines 2 and 3). Enter the total amount paid into the escrow account for this period. Amount over/under-paid (Difference between Line 4 and Line 5.) Provide explanation if not zero. Note: Attach a copy of your receipt or other proof of deposit from your financial institution. 1 2 3 0.0188482 4 5 6 $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Affidavit of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment Part 7: Designated Contact Name Mailing Address City Phone State Fax Zip Code E-Mail Country Title NPM-Q p. 3 of 3 Part 8: Manufacturer Certification Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Affidavit and any attached documents are true and accurate. This document must be signed and dated by an authorized notary public. NPM Authorized Designee (Print Name) Title Signature of NPM Authorized Designee Subscribed and sworn to before me this date: Date Signature of Notary Public County Commission Expires Checklist of required documents NPM-Q Affidavit of Non-Participating Manufacturer Regarding Quarterly Escrow Payment Proof of Deposit for Part 6 Any Brands Addendum pages for Part 3 Brand Sales Invoices or other documentation that supports the Illinois sales volume Mail to Submit the completed Affidavit and required documentation to the Tobacco Enforcement Bureau at this address: Office of the Illinois Attorney General Tobacco Enforcement Bureau 500 South Second Street Springfield IL 62706 For Additional Forms and Information Phone (217) 785-8541 Fax (217) 524-4701 www.IllinoisAttorneyGeneral.gov (Click on Tobacco) Rev. 2/20/2013 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Affidavit of Nonparticipating Manufacturer Regarding Quarterly Escrow Payment General Information What is the definition of a cigarette manufacturer? A cigarette manufacturer is defined as · any entity that manufactures cigarettes, including roll-your-own, anywhere that such manufacturer intends to be sold in the United States, including cigarettes that are intended to be sold in the United States through an importer; · the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States; or · a successor of any entity described above. NPM-Q Instructions Reconciliation affidavit A manufacturer who has made one or more quarterly payments for a liability year must make a final reconciliation payment and provide proof of deposit on or before April 15 of the year following the liability year. The reconciliation payment will include any sales which were not included on quarterly affidavits for the liability year. It will also include the final inflation adjustment for the liability year. What is a qualified escrow fund? An escrow arrangement with a U.S. federal or U.S. state chartered financial institution having no affiliation with any Tobacco Product Manufacturer and having assets of at least one billion dollars ($1,000,000,000) where such arrangement requires that the financial institution hold the escrowed funds' principal for the benefit of Releasing Parties and prohibits the Tobacco Product Manufacturer placing the funds into escrow from using, accessing or directing the use of the funds' principal except as consistent with the applicable NPM Statutes. All funds shall be held by the Escrow Agent in sub-accounts separate and apart from all other funds and sub-accounts of each Beneficiary State. What is a Non-Par
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