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Non-Participating Manufacturer (NPM) Quarterly Certificate Of Compliance - Nevada
| Non-Participating Manufacturer (NPM) Quarterly Certificate Of Compliance Form. This is a Nevada form and can be used in Tobacco Enforcement Unit Attorney Generals Office Statewide . |
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CATHERINE CORTEZ MASTO ATTORNEY GENERAL STATE OF NEVADA NON-PARTICIPATING MANUFACTURER (NPM) QUARTERLY CERTIFICATE OF COMPLIANCE Please type or print legibly. Any illegible certificate will be returned and deemed unfiled. PART 1: MANUFACTURER INFORMATION Company Name Address (Mailing and Physical) City/State/County Telephone Number Fax Number Email Website Name/Title of Person Completing Form PART 2: LIABILITY REPORTING PERIOD The liability period for this Certificate and Affidavit is: (check one below) January 1 through March 31, 2012 First Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before April 30, 2012 NPM Quarterly Certificate of Compliance received by Attorney General on or before May 10, 2012 Account letter submitted by bank to the Attorney General on or before May 10, 2012 April 1 through June 30, 2012 Second Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before July 31, 2012 NPM Quarterly Certificate of Compliance received by Attorney General on or before August 10, 2012 Account letter submitted by bank to the Attorney General on or before August 10, 2012 July 1 through September 30, 2012 Third Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before October 31, 2012 NPM Quarterly Certificate of Compliance received by Attorney General on or before November 12, 2012 Account letter submitted by bank to the Attorney General on or before November 12, 2012 October 1 through December 31, 2012 Fourth Quarter Deadlines: Escrow deposit to Nevada sub-account due on or before January 31, 2013 NPM Quarterly Certificate of Compliance received by Attorney General on or before February 11, 2013 Account letter submitted by bank to the Attorney General on or before February 11, 2013 Please note that the failure to submit this certificate by the above-referenced deadlines may result in the assessment of a civil penalty up to $1,000 per day. In addition, if an NPM fails to make timely and accurate escrow payments, the Office of the Attorney General may require that NPM to post a surety bond for a period of five years as a condition of continued directory listing. 1 American LegalNet, Inc. www.FormsWorkFlow.com PART III: QUARTERLY BRAND SALES Distributor Name Contact Name/Title Distributor Address Distributor Phone Brand Families Distributed Cigarettes or RYO Quarterly Distribution Volume 1 Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Distributor Name RYO Contact Name/Title Distributor Phone Distributor Address Brand Families Distributed Cigarettes or RYO Quarterly Distribution Volume Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Distributor Name RYO Contact Name/Title Distributor Address Distributor Phone Brand Families Distributed Cigarettes or RYO Quarterly Distribution Volume Cigarette RYO Cigarette RYO Cigarette RYO Cigarette Distributor Name RYO Contact Name/Title Distributor Address Distributor Phone Brand Families Distributed Cigarettes or RYO Quarterly Distribution Volume Cigarette RYO Cigarette RYO Cigarette RYO Cigarette RYO 1 Report all distribution volumes in units sold. Pursuant to NRS 370A.120, "units sold" is defined as the number of individual cigarettes sold in the state of Nevada either directly by the manufacturer or through an intermediate distributor. For roll-yourown (RYO) tobacco, units sold can be calculated by dividing the total ounces of RYO tobacco sold by 0.09. 2 American LegalNet, Inc. www.FormsWorkFlow.com PART IV: WORKSHEET FOR CIGARETTES SOLD DURING LIABILITY REPORTING PERIOD 1. Show on Line A the total units sold by the non-participating manufacturer in Nevada during the reporting period. (Note: For RYO, divide the total number of ounces sold by 0.09 and round up to the next whole unit.) A. _________ (units sold) 2. Line B contains the applicable rate per unit sold in 2012 ($0.0188482), plus the inflation adjustment for 2012 ($0.0102576). B. $0.0291058 3. Multiply Line A and B to determine the total escrow due for the liability reporting period. C. __________ PART V: CERTIFICATION OF ESCROW ACCOUNT AND AGREEMENT NOTE: The NPM certifies that it has established and continues to maintain a fully funded, qualified escrow account, pursuant to Chapters 370 and 370A of the Nevada Revised Statutes. Name of Financial Institution (Escrow Agent) Escrow Account Number Nevada Sub-Account Number Date of Escrow Deposit Amount of Escrow Deposit PART VI: ADDITIONAL INFORMATION Answer all of the following questions: A. The registered agent identified on this NPM's most recent Annual Certification submission continues to be the registered agent for this NPM: YES NO B. The financial institution information provided on this NPM's most recent Annual Certification remains accurate: YES NO C. The escrow agreement provided with this NPM's most recent Annual Certification remains in force and unchanged: YES NO D. If the answer to A, B and/or C above is NO, explain below and provide supporting documentation: 3 American LegalNet, Inc. www.FormsWorkFlow.com PART VII: AFFIDAVIT OF NPM An authorized officer of the NPM must sign this form, and this form MUST be notarized. Under penalty of perjury, I state that the NPM named in Part I, as of the date of this certification, is a non-participating manufacturer in full compliance with all applicable sections of NRS Chapters 370 and 370A. I am an authorized officer of the manufacturer. Through my position with the manufacturer, I am authorized to certify on behalf of the manufacturer and can legally bind the manufacturer. I understand that the Nevada Attorney General may require additional information and/or documentation relative to the assertions made in this Quarterly Certificate of Compliance. I have examined this Certificate, including attachments and supporting documents and, to the best of my knowledge and belief, this certification, including attachments and supporting documents, is true, correct, and complete. By signing this affidavit on behalf of the applicant company, I understand that the company is required to comply with state and federal laws concerning the sale of tobacco products. _______________________________________________________________________________________________ Name of Officer of NPM (print) Title _______________________________________________________________________________________________ Signature of Officer of NPM Date Subscribe and sworn to this date: ____________________________________________________________________ Count
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