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Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment DR 0237 - Colorado
| Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment Form. This is a Colorado form and can be used in Tobacco Dept Of Revenue Statewide . |
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DR 0237 (03/14/12) COLORADO DEPARTMENT OF REVENUE EXCISE TAX ACCOUNTING SECTION 1375 SHERMAN STREET., Rm 237 DENVER, CO 80261 www.TaxColorado.com STATE OF COLORADO CERTIFICATE OF COMPLIANCE BY NON-PARTICIPATING MANUFACTURER REGARDING ESCROW PAYMENT GENERAL INFORMATION What is the definition of a tobacco product manufacturer? · Any entity that manufactures cigarettes, including rollyour-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. When is this certificate of compliance due? ThiscertificateofcomplianceistobefiledonorbeforeApril 30thoftheyearfollowingthesalesyear.Thesalesyearisa calendaryearfromJanuary1throughDecember31. When must I make my escrow payment? You must deposit all escrow payments into your qualified escrowfundonorbeforeApril15thoftheyearfollowingthe salesyear.Afteryouhavemadeyourdeposit,forwardacopy of your receipt or other proof of deposit from your financial institutiontotheOfficeoftheAttorneyGeneraloftheStateof Colorado,alongwiththissignedandnotarizedcertificateof compliance.Inaddition,afteryouhavemadeyourinitialdeposit intothequalifiedescrowfund,forwardacopyoftheescrow agreementasexecuted.Finally,forwardanyamendmentsto theescrowagreement. SPECIFIC INSTRUCTIONS: Part 1: Manufacturer's Identification. Writeyourname,address,telephoneandfaxnumber. Part 2: Sales Year. Writethesalesyear. Part 3: Units Sold. Writethenumberofindividualcigarettesandtheamountof "roll-your-own"tobacco(.09ouncesconstitutesonecigarette) manufacturedbyyouandsoldduringthesalesyearinColorado. Alsoincludethebrandnamesforwhichyouareremittingan escrowpayment.Providesalesorinvoicedocumentationto support"unitssold"figures.Ifyouconsidertheinformationyou areattachingtobeatradesecret,orconfidentialcommercial orfinancialdata,youshouldmarkthedocument(s)assuch beforeyousendittothisoffice. Part 4: Escrow Rates and Payments. Multiplytheunitssoldbytheappropriaterateforthesalesyear andwritetheresultasyoursubtotal.Addthesubtotalandthe inflationadjustmentamounttoarriveatthetotaldeposittobepaid intoyourqualifiedescrowaccountfortheapplicablesalesyear. Part 5: Financial Institution. Writethenameandaddressofthefinancialinstitutionholding yourescrowaccount.Includeyourescrowaccountnumber. Part 6: Escrow Deposit/Withdrawal History for Colorado Write in the date, deposit/withdrawal amount and balance foreachtransaction.Alsowritethetotalcumulativeamount currentlyinyourescrowaccountforthebenefitoftheState ofColorado. Part 7: Signature. An authorized notary public must also sign and date this certificateofcompliance. American LegalNet, Inc. www.FormsWorkFlow.com · · Who is required to file this certificate of compliance? · Anytobaccoproductmanufacturerthat: (1) sellscigaretteswithinthestateofColorado(whether directlyorthroughanydistributor,retailer,orsimilar intermediary)and (2) has not become a participating manufacturer in the tobacco Master SettlementAgreement executed on 11/23/98(theMSA). If you satisfy these requirements, you must file this certificate of compliance to report the units of cigarettes manufactured by you and sold in the state of Colorado and pay the amount calculated into your qualified escrow fund. What is a non-participating manufacturer? A non-participating manufacturer is any tobacco product manufacturer who has not signed onto the MSA.All nonparticipatingmanufacturersarerequiredtofilethisCertificate ofCompliance. What is a qualified escrow fund? A non-participating manufacturer that is required to file this certificate of compliance must establish a qualified escrow fund.ThismeansanescrowarrangementwithaU.S.federal orU.S.state-charteredfinancialinstitutionhavingnoaffiliation withanytobaccoproductmanufacturerandhavingassetsof at least USD $1,000,000,000.00 where such arrangement (1) requires that the financial institution hold the escrowed funds'principalforthebenefitoftheStateofColorado(and possiblyother"ReleasingParties"asdefinedintheMSA)and (2) prohibits the non-participating manufacturer from using, accessing,ordirectingtheuseofthefunds'principalexcept asconsistentwithColorado'sTobaccoEscrowFundsLaw(§ 39-28-203,C.R.S.(2001)). CERTIFICATE OF COMPLIANCE BY NON-PARTICIPATING MANUFACTURER REGARDING ESCROW PAYMENT PART 1: Manufacturer's Identification Name Address Phone Email Fax WebSiteAddress PART 2: Sales Year TheyearofsalesfortheCertificateofComplianceis:__________(Completeaseparatecertificateforeachyearofsales.) PART 3: Units Sold (AttachAdditionalSheets,ifnecessary) Indicate with an asterisk (*) those brands that will not be sold in 2012. The brands indicated with an asterisk (*) will be removedfromtheColoradoCertifiedBrandsDirectorythemonthfollowingthereceiptoftheCertificateofComplianceforthe 2011yearofsales. A. BRAND FAMILY* B. BRAND NAME C. CIGARETTE OR RYO C. UNITS SOLD D. MANUFACTURER PART 4: Escrow Rates and Payments For Sales Year: Total units sold during sales year: _________________________________(forRYOdivideouncessoldby.09) Documentation to support the "units sold," including but not limited to invoices, spreadsheets and sales statements, must be attached and filed with this Certificate of Compliance. Escrow Rate:forsalesyear2011,theratepercigaretteis$0.0188482. Escrow deposit subtotal: $__________________________________(multiplytotalunitssoldbyescrowrate) Inflation adjustment:Theappropriateinflationadjustmentforsalesyear2011is49.92446%.Forpaymentsdue April15,2012,multiplyEscrowDepositenteredaboveby.$ . Escrow deposit paid:Thetotalamountthathasbeenpaidintothequalifiedescrowfundbythemanufactureridentified aboveforthesalesyear2011is$ (adddepositsubtotalandinflationadjustment) A copy of your executed Escrow Agreement and any amendment to the Escrow Agreement, a current escrow account statement from the financial institution for the Colorado sub-account, and copies of your receipt or other proof of deposit from your financial institution, must be attached and filed with this Certificate. NOTE: THE STATE OF COLORADO WILL NOT PROCESS INCOMPLETE OR ILLEGIBLE CERTIFICATIONS. ATTACH ADDITIONAL SHEETS AS NECESSARY TO PROVIDE A COMPLETE RESPONSE. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF COMPLIANCE BY NON-PARTICIPATING MANUFACTURER REGARDIN
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