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Certification Of Compliance And Affidavit By Nonparticipating Manufacturer TPM-1 - Connecticut
| Certification Of Compliance And Affidavit By Nonparticipating Manufacturer Form. This is a Connecticut form and can be used in Cigarette And Tobacco Products Taxes Department Of Revenue Services Statewide . |
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State of Connecticut Form TPM-1 (Rev. 03/11) Certification for calendar year 2010 Certification of Compliance and Affidavit by Nonparticipating Manufacturer Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2010 Complete this form in blue or black ink only. An authorized agent of the nonparticipating manufacturer must complete and sign Part I before a notary public. The nonparticipating manufacturer is also responsible for having an authorized agent of the financial institution complete and sign Part II before a notary public and for filing Form TPM-1, Certification of Compliance and Affidavit by Nonparticipating Manufacturer, with the Office of the Attorney General on or before April 30, 2011. Attach Form TPM-3, Brand Families Unit Sales Schedule, to this form. Read the additional instructions on the back of this form. Part I To be completed by a nonparticipating manufacturer and signed before a notary public. 1. Name of nonparticipating manufacturer 3. Address 5a. City, town, or post office 7. Name of financial institution holding the qualified escrow fund for Connecticut Number and street PO Box 5b. State or province 5c. Country 2. Telephone number ( ( ) ) 4. Facsimile (Fax) number 6. Email address 8. Account and sub-account numbers of the qualified escrow fund for Connecticut 9. Number of nonparticipating manufacturer's cigarettes sold to consumers within Connecticut whether directly or through a distributor, dealer, or similar intermediary or intermediaries during calendar year 2010 10. Amount required to be placed into the qualified escrow fund for Connecticut sales: Multiply Line 9 by $0.0274350. 11. Amount placed into the qualified escrow fund for Connecticut and attributable to Connecticut sales reported on Line 9 12. Account balance of the qualified escrow fund for Connecticut, including amount reported on Line 11 $ $ $ . . . Declaration: I declare under the penalty of false statement that I have examined Part I of this form and, to the best of my knowledge and belief, it is true, complete, and correct. The penalty for false statement is imprisonment not to exceed one year, a fine not to exceed $2,000, or both. I authorize the financial institution named above to verify the balance in the bank account identified above, and any deposits thereto and withdrawals therefrom, for the State of Connecticut, Office of the Attorney General, upon request by that office. _______________________________________________________ Signature of authorized agent of nonparticipating manufacturer _____________________________________________ Printed or typed name of authorized agent ___________________________ Title of authorized agent __________ Subscribed and sworn to before me this _______________________________________day of ________________________________ , 20 ______________________________________________ Signature of notary public My commission expires: ____________________________ Part II To be completed by financial institution holding qualified escrow fund and signed before a notary public. Name of financial institution holding the qualified escrow fund Address Number and street PO Box Telephone number ( ) Fax number ( City, town, or post office State ZIP code ) Email address Declaration: I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into the bank account identified above and that I have examined Part II of this form and, to the best of my knowledge and belief, it is true, complete, and correct. The penalty for false statement is imprisonment not to exceed one year, a fine not to exceed $2,000, or both. In accordance with the authorization given by the nonparticipating manufacturer mentioned above, I agree to verify the balance in the account identified above, and any deposits thereto and withdrawals therefrom, for the State of Connecticut, Office of the Attorney General, upon request by that office. _______________________________________________________ Signature of authorized agent of financial institution _____________________________________________ Printed or typed name of authorized agent ___________________________ Title of authorized agent __________ Subscribed and sworn to before me this _______________________________________day of ________________________________ , 20 ______________________________________________ Signature of notary public My commission expires: ____________________________ American LegalNet, Inc. www.FormsWorkFlow.com Form TPM-1 Instructions Who Must File Each nonparticipating manufacturer selling cigarettes to consumers within Connecticut, whether directly or through a distributor, dealer, or similar intermediary or intermediaries, must establish a qualified escrow fund for the benefit of the State of Connecticut and other settling states, place the required amount of money into a qualified escrow fund, and file Form TPM-1, Certification of Compliance and Affidavit by Nonparticipating Manufacturer. Tobacco product manufacturer means any entity, which after July 1, 2000, directly and not exclusively through an affiliate: a. Manufactures cigarettes anywhere which the manufacturer intends to be sold in the United States, including cigarettes intended to be sold in the United States through an importer; b. Is 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 c. Becomes a successor of an entity described above. Master Settlement Agreement means the agreement that the settling states and the original participating manufacturers entered into on November 23, 1998. Under MSA, the parties settled and resolved all claims by the settling states directly or indirectly based on the sale, distribution, manufacture, development, advertising, and marketing of tobacco products by the participating manufacturers. MSA required, among other things, each of the settling states enact a model statute. Settling states means the 46 states, including Connecticut, that signed the MSA on or before November 23, 1998. Qualified escrow fund means an escrow arrangement with a federally or state-chartered financial institution having no affiliation with any tobacco product manufacturer. The financial institution must have assets of at least $1 billion. The escrow arrangement must require that the financial institution hold the principal of the escrowed funds for the benefi
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