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Quarterly Escrow Compliance Certificate And Affidavit (NPM) - Oregon
| Quarterly 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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QUARTERLY ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Nonparticipating Manufacturer) Part 1: Reporting Period SALES YEAR: ___________ SALES QUARTER: __________________ NOTE: YOU MUST ALSO FILE AN ANNUAL ESCROW COMPLIANCE CERTIFICATE ON OR BEFORE APRIL 25 EACH YEAR. THE ANNUAL FORM IS IN ADDITION TO THIS QUARTERLY FORM. You can obtain the annual form at www.doj.state.or.us Part 2: Manufacturer's Identification Name: ___________________________________________________________________ Physical Address: ___________________________________________________________ Mailing Address :____________________________________________________________ Phone: __________________________________ FAX ___________________________ E-Mail Address (Optional): ___________________________ Part 3: Units Sold Number of units of individual cigarettes and roll-your-own tobacco RYO), 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 Nonparticipating 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 QUARTERLY ESCROW COMPLIANCE CERTIFICATE PAGE 1 of 2 CEDW3192 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 (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 #________________ 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. Attached is a copy of the escrow agreement between the tobacco product manufacturer and the financial institution. If a copy previously has been provided, and the terms of the escrow agreement have not changed, then a statement of that fact will satisfy the requirement of providing a copy of the escrow agreement. 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 certifications 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 Quarterly 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 QUARTERLY ESCROW COMPLIANCE CERTIFICATE PAGE 2 of 2 CEDW3192 American LegalNet, Inc. www.FormsWorkflow.com
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