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Certification Of Non-Participating Manufacturer NPM-1 - Illinois
| Certification Of Non-Participating Manufacturer 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 Certification of Non-Participating Manufacturer Please Review Instructions Prior to Completion. NPM-1 p. 1 of 4 Part 1: Liability Year and Type of Certification Liability Year for this Certification: Complete a separate form for each liability year for which you are certifying. (check one) Type of Certification: (check one) Initial 2012 Annual Other: ______ Supplemental 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 Family Certification (Attach Brands Addendum pages as necessary) The undersigned manufacturer certifies, under penalty of perjury, as of the date of this certification, it is a Non-Participating Manufacturer (NPM) and is in full compliance with the Escrow Act and the Escrow Enforcement Act of 2003 as well as any regulations and quarterly installment payments. The undersigned NPM certifies that the following list is a complete list of all of its brand families which are to be deemed to be its cigarettes (including RYO product) for purposes of Section 15 of the Escrow Act. Nothing in this certification shall limit or otherwise affect the State's right to maintain that a brand family constitutes cigarettes or roll-your-own tobacco of a different tobacco product manufacturer for purposes of Section 15 of the Escrow Act. For each brand style that the Fire Marshal has approved and for which the Attorney General's Office has approved the Brand Family, provide the following information: Brand Style, Size (100 or Kings), Flavor, Filter (y/n) and Package (Soft/Box) as it should be listed on the Illinois Directory. Provide corrections, if any, for the brand style information for FSC cigarettes listed on the Illinois Directory. Include with your certification sample packaging for each brand family named. Packaging for FSC products must be provided when changes are made to the packaging or new products are certified for listing and sale in Illinois. Packaging provided for cigarettes must reflect compliance with the Cigarette Fire Safety Standard Act (425 ILCS ยง8/1, et seq.). Submit new packaging each time you change your packaging or add new brand families. Brand Family Asterisk (*) denotes brands which are no longer sold in Illinois Check One Report Units Sold in Sticks for Cigarettes and in Ounces for RYO Check indicates Packaging is Submitted Name & address of manufacturer of brand family in 2011 if different from NPM identified in Part 2 Units Sold in 2012 Units Sold in 2013 Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO Total of RYO Ounces Total of Cigarette Sticks American LegalNet, Inc. www.FormsWorkFlow.com State of Illinois Certification of Non-Participating Manufacturer Please Review Instructions Prior to Completion. NPM-1 p. 2 of 4 Part 4: Certification of Escrow Account and Agreement 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 $ Yes No Are funds held for the benefit of the State of Illinois in any account other than that listed above? write If you answered "yes,"Yes the total amount of all funds which are being held in any account for the benefit of the State of Illinois, including the amount listed above. Has the Qualified Escrow Agreement been approved by the Attorney General? Attach an executed copy of your current escrow agreement whether or not it has already been approved by the Attorney General. $ Yes No Date of Agreement: __________________ Approval Date: __________________ Part 5: Worksheet for Cigarettes Sold During Liability Year 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: 2012 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 liability year. 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 2012 liability period, the inflation adjustment percentage is 54.42219 percent (multiplier of .5442219). 4 5 6 Enter the total amount to be paid into the escrow account for this liability year 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 liability year. 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. American LegalNet, Inc. www.FormsWorkFlow.com 1 2 3 0.0188482 4 5 6 $ $ $ State of Illinois Certification of Non-Participating Manufacturer Please Review Instructions Prior to Completion. NPM-1 p. 3 of 4 Part 7: Certification of Deposits, Withdrawals and Transfers Attach separate page for each sub-account. The NPM certifies the following to be a complete record of each deposit and withdrawal or transfer which has occurred from any and all accounts containing funds held for the benefit of the State of Illinois. Report ending balances of all such accounts, even where no deposits or withdrawals occurred. Attach copies of records of the financial institution documenting any account activity. Illinois Sub-Account Number Name of Financial Institution (Escrow Agent) Date Deposit Amount Withdrawal or Transfer Amount Explanation for Withdrawal or Transfer Deposits Column Totals $ Withdrawals/Transfers $ $ Ending Balance for this Illinois Sub-Account American LegalNet, I
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