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Montana Certificate Of Escrow Deposit By Non-Participating Manufacturer - Montana
| Montana Certificate Of Escrow Deposit By Non-Participating Manufacturer Form. This is a Montana form and can be used in Tobacco Department Of Justice Statewide . |
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Montana Certificate of Escrow Deposit by Non-Participating Manufacturer Part 1: Manufacturer Identification Name: Street address: City, State, Country, ZIP: Telephone number: E-mail address: Fax number: Name of distributor(s)/wholesaler(s) that sells your cigarettes in Montana and brand(s) sold: Part 2: Liability Year. The liability year for this certificate is: 2011 Part 3: Units Sold 1. Number of individual cigarettes and units of "roll-your-own" tobacco sold by the manufacturer during 2011 1. Part 4: Deposit Amount 2. The deposit amount for 2011 is $.0188482 per unit sold. The 2011 inflation adjustment is $.0094099 per unit sold. The total amount due, adjusted for inflation, is $.0282581. 2. $.0282581 3. Multiply line 1 by line 2 to calculate the total deposit due. 3. Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the institution. Part 5: Financial Institution Name: Street address: City, State, Country, ZIP: Escrow account number: Total amount held in this account: $ Part 6: Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. This document must be signed and dated by an authorized notary public. SWORN AND SUBSCRIBED TO before me this ____ day of _________________, 20 . Date (SEAL) Signature of Authorized Agent Signature of Notary Public Printed Name of Authorized Agent Printed Name of Notary City / State: My Commission Expires: Title Montana Department of Justice Revised January 2012 2011 Certificate of Escrow Deposit by Non-Participating Manufacturer Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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