Alaska > Statewide > Department Of Revenue > Tax Division
Tobacco Product Manufacturer Certificate Of Compliance 04-510 - Alaska
| Tobacco Product Manufacturer Certificate Of Compliance Form. This is a Alaska form and can be used in Tax Division Department Of Revenue Statewide . |
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Name of Manufacturer Mailing Address City Name of Person Completing Report State Title Zip Code Phone Number Email Address Contact Phone Number ompliance (see instructions) T (initial one) A Participating Manufacturer under the Tobacco Master Settlement Agreement A Non-participating Tobacco Product Manufacturer in full compliance with AS 45.53. Part II: Sales Year (see instructions) The year of sales (attach additional sheets if necessary) C. Units Sold in AK Preceding Year D. Units Sold in AK Current Year E. Other Manufacturer of (A) in Preceding Year A. B. Total Units Sold.................................................... Mail to: ALASKA DEPARTMENT OF REVENUE TAX DIVISION 550 W SEVENTH STE 500 ANCHORAGE AK 99501-3555 0405-510 Revised 0 /12 - page 1 American LegalNet, Inc. www.FormsWorkFlow.com 1. Cigarettes Sold In Alaska. Enter the number of cigarettes sold in Alaska during the sales year. ............................................................................................................................................ Sales Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... The rate per cigarette is...................................... A Escrow Rate 0.0094241 0.0104712 0.0136125 0.0136125 0.0167539 0.0167539 0.0167539 0.0167539 0.0188482 0.0188482 0.0188482 0.0188482 0.0188482 B 0.0002827 0.0006794 0.0013181 0.0017660 0.0027414 0.0033761 0.0040637 0.0046882 0.0062587 0.0070119 0.0077877 0.0085868 0.0094099 C 0.0097068 0.0111506 0.0149306 0.0153785 0.0194953 0.0201300 0.0208176 0.0214421 0.0251069 0.0258601 0.0266359 0.0274350 0.0282581 Multiply the number of cigarettes sold on line 1 by the appropriate rate in column C. ................................................................................................ $ (To be completed by Authorized Agent of Financial Institution where the escrow account was established) Representative Name Name of Institution Mailing Address Escrow Account Number City State Account Number State Email Address Zip Code Phone Number .......................................... $ ............................... $ Date Date Deposit Withdrawal Balance applicable sales year. 0405-510 Revised 0 /12 - page 2 American LegalNet, Inc. www.FormsWorkFlow.com (must be completed by both PMs and NPMs) 1. Are you registered with ATF? Yes No 2. Are you registered to do business in Alaska? Yes No Agent Name Company Name Mailing Address Email Address City Phone Number State Zip Code Part VI: Signatures where the escrow account is maintained) Printed Name of Authorized Agent of Manufacturer Title Signature of Authorized Agent of Manufacturer Date Printed Name of Authorized Agent of Financial Institution Title Signature of Authorized Agent of Financial Institution Date Subscribed and sworn to before me on this date Signature of Notary Public City or County of 0405-510 Revised 0 /12 - page 3 American LegalNet, Inc. www.FormsWorkFlow.com
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