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Certificate Of Compliance By Non Participating Manufacturer Regarding Escrow Payment - Alabama
| Certificate Of Compliance By Non Participating Manufacturer Regarding Escrow Payment Form. This is a Alabama form and can be used in Tobacco Tax Alabama Department Of Revenue Statewide . |
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ALABAMA DEPARTMENT OF REVENUE BUSINESS & LICENSE TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 · Montgomery, AL 36132-7555 · (334) 242-9627 www.revenue.alabama.gov TOB: NPM-ESC CERT 3/12 Certificate of Compliance by Non-Participating Manufacturer Regarding Escrow Payment PART 1 MANUFACTURER'S IDENTIFICATION Name: _____________________________________________________________________ FEIN: Address: _____________________________________________________________________________________________________ City: ____________________________ State: ___________________ Zip/Postal Code: _____________ Country: ________________ Telephone Number: (_______)_______________________ PART 2 SALES YEAR/QUARTER The Year and/or Quarter (if applicable) of Sales for this Certificate of Compliance is: ________ Year 1 2 3 4 FAX Number: (_______)_______________________ Quarter (check quarter, if applicable) (Complete a separate certificate for each year or quarter of sales. If you have been required to make deposits and certifications quarterly, quarters are divided as follows: January 1- March 31; April 1- June 30; July 1- September 30; and October 1- December 31.) PART 3 UNITS SOLD Number of individual cigarettes and "roll-your-own" tobacco sold in Alabama (directly or indirectly) by the Manufacturer identified above during the sales year or quarter: (See instructions for details.) __________________________________ PART 4 ESCROW RATES AND PAYMENTS For the sales year: (Use and adjust the rates listed below to figure the appropriate total deposit amount.) 1999 2000 2001 2003 2007 The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 2002 The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . - 2006 The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . and thereafter The rate per cigarette is . . . . . . . . . . . . . . . . . 0.0094241 0.0104712 0.0136125 0.0167539 0.0188482 The appropriate DEPOSIT SUBTOTAL is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ (Multiply units in Part 3 by the appropriate rate in Part 4) The appropriate INFLATION ADJUSTMENT for the sales year is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________ (Please refer generally to Exhibit C of the tobacco Master Settlement Agreement for calculation of the cumulative adjustment for inflation applicable to each year's escrow payment. For payments due April 15 multiply the deposit subtotal by the appropriate rate listed below to figure the appropriate total deposit amount.) 1999 Inflation rate is 2000 Inflation rate is 2001 Inflation rate is 2002 Inflation rate is 2003 Inflation rate is 2004 Inflation rate is 2005 Inflation rate is 2006 Inflation rate is 2007 Inflation rate is 2008 Inflation rate is 2009 Inflation rate is 2010 Inflation rate is 2011 Inflation rate is ...................... 3% (0.030000000) . . . . . . . . . . . . . . . . . . . . . . 6.4884136% (0.064884136) . . . . . . . . . . . . . . . . . . . . . . 9.6830623% (0.096830623) . . . . . . . . . . . . . . . . . . . . . . 12.97355% (0.129735500) . . . . . . . . . . . . . . . . . . . . . . 16.3627565% (0.163627565) . . . . . . . . . . . . . . . . . . . . . . 20.15103% (0.201510300) . . . . . . . . . . . . . . . . . . . . . . 24.25497% (0.242549700) . . . . . . . . . . . . . . . . . . . . . . 27.98262% (0.279826200) . . . . . . . . . . . . . . . . . . . . . . 33.20594% (0.332059400) . . . . . . . . . . . . . . . . . . . . . . 37.20212% (0.372021200) . . . . . . . . . . . . . . . . . . . . . . 41.31818% (0.413181800) . . . . . . . . . . . . . . . . . . . . . . 45.55773% (0.455577300) . . . . . . . . . . . . . . . . . . . . . . 49.92446% (0.499244600) If you have been required to make a quarterly deposit and certification for the 2012 sales year, the estimated inflation rate is 54.42219%. Adjustments may be made requiring additional deposits or credits if this estimated rate is not correct. Please refer to the NPM instructions for information regarding escrow deposit and certification dates. TOTAL AMOUNT that has been paid into the Qualified escrow fund by the Manufacturer identified above for the sales year or quarter. (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. American LegalNet, Inc. www.FormsWorkFlow.com PART 5 FINANCIAL INSTITUTION Name of Institution: ____________________________________________________________________________________________ Address: _____________________________________________________________________________________________________ City: __________________________________________ State: ___________________________ Zip Code: _____________________ Escrow Account Number: __________________________________ State Account Number: _________________________________ PART 6 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. Name of Authorized Agent (Print): _____________________________________________ Title: ______________________________ Signature of Authorized Agent: __________________________________________________ Date: ____________________________ Subscribed and sworn to before me on this date: ___________________________________ Signature of Notary Public: _____________________________________________________ Notary for the State of: ___________________________________ City or County of: _______________________________________ My Commission expires: _______________________________________________________ Mail this Certificate of Compliance to: Alabama Department of Revenue Attn: Commissioner of Revenue P. O. Box 327555 Montgomery, AL 36132-7555 American LegalNet, Inc. www.FormsWorkFlow.com ALABAMA DEPARTMENT OF REVENUE SALES, USE & BUSINESS TAX DIVISION TOBACCO TAX SECTION P.O. Box 327555 · Montgomery, AL 36132-7555 · (334) 242-9627 www.revenue.alabama.gov TOB: NPM-ESC INST 4/10 Instructions for Certificate of Compliance by Non-Participati
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