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Certification Of Compliance By Nonparticipating Manufacturer (NPM) 3762 - Michigan
| Certification Of Compliance By Nonparticipating Manufacturer (NPM) Form. This is a Michigan form and can be used in Tobacco Tax Department Of Treasury Statewide . |
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Michigan Department of Treasury Form 3762 (Rev. 02-13) Certification of Compliance by Nonparticipating Manufacturer (NPM) PART I - NOTIFICATION OF ESCROW DEPOSIT Issued under authority of Public Act 327 of 1993. Filing is mandatory. 1. NPM Name 3. Address (Street, City, State, ZIP Code) 4. Telephone Number 5. Fax Number SECTION 1: TOBACCO PRODUCT MANUFACTURER'S IDENTIFICATION - see instructions on page 2. 2. Contact Person SECTION 2: FINANCIAL INFORMATION Use the chart below to complete lines 7 through 9 (Units Sold x Rate Per Unit = Escrow Amount). Attach a copy of your receipt or other proof of deposit from your financial institution, and your current notice of resident agent. Sales Year *Rate Per Unit Sold (adjusted for inflation) 2007 .....................................................................................................................................0.0251069 2008 .....................................................................................................................................0.0258601 2009 .....................................................................................................................................0.0266359 2010 .....................................................................................................................................0.0274350 2011......................................................................................................................................0.0282581 2012 .....................................................................................................................................0.0291058 6. 7. Sales Year. For this Certification only (complete a separate Certification for each year of sales) .............................................................................................................................. 6. Units Sold. Number of individual cigarettes including "roll-your own" tobacco (.09 ounces of "roll-your-own" tobacco = one cigarette) produced by the Manufacturer identified in Section 1 and reported as sold during the year identified on line 6 for stamping and consumption in Michigan (see instructions for details) ........................................................................................ 7. Rate Per Unit from chart above, for the Sales Year listed on line 6............................................ 8. Escrow Amount. Amount paid into the qualified Escrow Account by the Manufacturer $ identified in Section 1 (attach proof of deposit). Multiply line 7 by line 8 .................................... 9. 8. 9. SECTION 3: FINANCIAL INSTITUTION 10. Name of Financial Institution 11. Address (Street, City, State, ZIP Code) 12. Michigan Escrow Account Number 13. Total Amount Held in Escrow for Michigan SECTION 4: SIGNATURE I declare under penalty of perjury that the information contained in this Certification of Compliance and attachments is true and complete to the best of my knowledge. This document must also be signed and dated by an authorized notary public. Name of Officer or Authorized Agent Title Signature of Officer or Authorized Agent Date State of City of ___________________________ ___________________________ Subscribed and sworn to before me this date: _______________________ My commission expires _________________________________________ Signature of Notary ____________________________________________ County of ___________________________ For questions, contact (517) 636-4630. You must make your deposit by April 15th and submit this Certification of Compliance by April 30th each year. Mail the original Certification (PARTS I and II), notice of resident agent, and deposit receipt to: Tobacco Tax Unit, Michigan Department of Treasury, P.O. Box 30474, Lansing, MI 48909. Also mail a copy to: Environment, Natural Resources and Agriculture Division, Office of Attorney General, 525 W. Ottawa, P.O. Box 30212, Lansing, MI 48909. If your name does not appear on the list published at www.michigan.gov/tobaccotaxes identifying authorized NPM's and their brands, you are prohibited from selling, or having your brands sold for consumption in Michigan. American LegalNet, Inc. www.FormsWorkFlow.com Form 3762 Page 2 Certification of Compliance by Nonparticipating Manufacturer PART II - BRAND CERTIFICATION Issued under authority of Public Act 327 of 1993. Filing is mandatory. This certification is used as a basis for identifying brands authorized for purchase during the calendar year following the year identified on line 6 (Part I), unless otherwise noted at www.michigan.gov/tobaccotaxes. Form must be provided by April 30 of the year following the year identified on line 6 (Part 1). NPM Name Address Telephone Number Fax Number E-mail Address FE, ME, or TR No. I,________________________________ , in my capacity as________________________ of _____________________ , hereby certify that: _________________________________has performed its obligations under Public Act 244 of 1999 to establish and deposit funds in a qualified escrow account for sales of our cigarettes, including "Roll-Your-Own" (RYO) Tobacco, and met its obligations under Public Act 327 of 1993, during calendar year _____________________________ . SCHEDULE K2 - NPM BRANDS SOLD FOR CONSUMPTION IN MICHIGAN DURING CALENDAR YEAR ____ (from line 6, Part I). The schedule below must be filled out in its entirety by listing brand names sold for consumption in Michigan during the previous calendar year. This certificate is not valid if the Schedule below is not completed. Attached additional sheets if necessary. Brand Name Cigarette or RYO Tobacco Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette Cigarette RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco RYO Tobacco I declare under penalty of perjury that the information contained in this certification and any attachments is true and correct to the best of my knowledge. Name Title Signature Date A copy of PART II - BRAND CERTIFICATION of the Certification of Compliance must be provided to all of your customers who might sell the above listed products in Michigan directly or through an intermediary. DO NOT provide a copy of PART I - NOTIFICATION OF ESCROW DEPOSIT to anyone other than the Department of Treasury or the Office of the Attorney General. For questions, contact (517) 636-4630. American LegalNet, Inc. www.FormsWorkFlow.c
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