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Annual Escrow Compliance Certificate And Affidavit (NPM) - Oregon
| Annual Escrow Compliance Certificate And Affidavit (NPM) Form. This is a Oregon form and can be used in Civil Enforcement Division Office Of Attorney General Statewide . |
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ANNUAL ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Non-Participating Manufacturer) Part 1: Reporting Period SALES YEAR: _______________ * If your company is required to make quarterly escrow deposits you must complete the Quarterly Escrow Compliance Certificate and Affidavit. Part 2: Manufacturer's Identification Name: _____________________________________________________________________________ Physical Address: ____________________________________________________________________ Mailing Address:_____________________________________________________________________ Phone: __________________________________ FAX: _____________________________________ E-Mail: ___________________________ Part 3: Units Sold Number of units of individual cigarettes and roll-your-own (RYO) tobacco sold in Oregon by the Manufacturer identified above during the sales reporting period is as follows: ___________Total Number Units of Cigarettes ___________Total Ounces of Roll-Your-Own (RYO) ___________Total Number of Units of RYO (One unit =.09 ounces of RYO) ___________TOTAL NUMBER OF ALL UNITS Non-Participating Manufacturer Brand Information: (Please add additional sheets if necessary) Brand Name (Omit styles such as Regular, Menthol, Light, etc.) Cigarettes = C Roll Your Own = RYO Number of Units Sold During the Reporting Period ANNUAL ESCROW COMPLIANCE CERTIFICATE PAGE 1 of 2 CEDW3190 American LegalNet, Inc. www.FormsWorkflow.com Part 4: Calculation of Deposit Amount For the sales reporting period: 1999- The rate per cigarette is .................................. 2000- The rate per cigarette is .................................. 2001-2002-The rate per cigarette is ............................. 2003-2006-The rate per cigarette is ............................. 2007 and thereafter The rate per cigarette is ................. 0.0094241 0.0104712 0.0136125 0.0167539 0.0188482 A. The appropriate rate for the reporting period is: ......................................... B. Deposit Subtotal (Multiply total number of all units in Part 3 by the appropriate cigarette rate in Part 4 above) .............................................................................................................. ___________________ ___________________ ___________________ ___________________ C. The Inflation Adjustment (Refer to www.doj.state.or.us). Multiply Line B Deposit Subtotal by the applicable inflation adjustment percentage.)........................................... D. Total Escrow Deposit (Add Line B Deposit Subtotal and Line C Inflation Adjustment) ..................................................................... Part 5: Financial Institution Name of Institution: __________________________________________________________ Authorized Contact Name and Title:_______________________ Phone #:_______________ Fax:_____________________________ Email: ____________________________________ Address: ___________________________________________________________________ Escrow Acct. No: ___________________ Sub-Acct Number (if applicable)______________ Total Funds Held in a Separate Account for Oregon: ________________________________ Date of Escrow Agreement:____________________________________________________ Date of Last Amendment to Escrow Agreement:____________________________________ Attached is a copy of the financial institution's receipt or other proof of deposit of the proper escrow payment. Part 6: Signature Under penalty of perjury, I declare that I am authorized to certify on behalf of the Tobacco Product Manufacturer in Part 1 that all of the information contained in this Escrow Compliance Certificate, including but not limited to the attachments herewith, are true, complete and accurate. This Escrow Compliance Certificate must also be signed and dated by an authorized notary public. Name of Authorized Agent:_______________________________ Title: ________________ Signature of Authorized Agent: ____________________________ Date:_________________ Subscribed and sworn to before me on this date: ______________________________________ Signature of Notary Public: ____________________________ City or County of: ___________ My Commission expires: ______________________________ Mail this Escrow Compliance Certificate Affidavit with attachments to: Office of the Attorney General for the State of Oregon Department of Justice, Civil Enforcement Division 1162 Court Street NE Salem, OR 97301-4096 Phone: (503) 934-4400 Fax: (503) 373-7067 ANNUAL ESCROW COMPLIANCE CERTIFICATE PAGE 2 of 2 CEDW3190 American LegalNet, Inc. www.FormsWorkflow.com
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