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Certification Of Brand Family And Units Sold NPM-US - New Jersey
| Certification Of Brand Family And Units Sold Form. This is a New Jersey form and can be used in Tobacco Enforcement Office Of The Attorney General Statewide . |
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State of New Jersey Certification of Brand Family and Units Sold Part 1: Certification Year and Type of Certification Certification Year: Complete a separate form for each certification year for which you are certifying. Certification year 2013 is for sales made in 2012. (check one) Type of Certification: (check one) Initial NPM-US 2013 Annual Other:______ Supplemental Part 2: M anufacturer Identification Company Name Mailing Address City Phone State Fax Zip Code Web Address Country FEIN Name and Title of Person Completing this Form Part 3: Brand Family Certification (Attach Brands Addendum pages as necessary) The undersigned manufacturer certifies, under penalty of perjury, as of the date of this certification, it is a Non-Participating Manufacturer (NPM) and is in full compliance with N.J.S.A. 52:4D-1et.seq. The undersigned NPM certifies that the following list is a complete list of all of its brand families which are to be deemed to be its cigarettes (including RYO product) for purposes of N.J.S.A. 52:4D-1et.seq. Nothing in this certification shall limit or otherwise affect the State's right to maintain that a brand family constitutes cigarettes or roll-your-own tobacco of a different tobacco product manufacturer for purposes of N.J.S.A. 52:4D-1et.seq. Include with your certification sample packaging for each brand family named. If you have previously supplied packaging to the Attorney General, and if the packaging has not changed, samples need not be supplied with this certification. You must submit new packaging each time you change your packaging or add new brand families. Flavoring Check Here if your cigarette/ RYO has a characterizing flavor other menthol, clove or tobacco, N.J.S.A. 2A: 170-51.6 Report Units Sold in Sticks for Cigarettes and in Ounces for RYO Brand Family Check One Units Sold in 2011 Units Sold in 2012 Packaging Check Here if packaging was previously submitted and is unchanged, N.J.S.A. 52:4D-10.d. 9 Cigarette 9 RYO 9 Cigarette 9 RYO 9 Cigarette 9 RYO 9 Cigarette 9 RYO 9 Cigarette 9 RYO Total of RYO Ounces Total of Cigarette Sticks **Have you attached a copy of your Federal PACT Registration form as filed with the United States Department of Justice? Yes_____ No_____ If No, please explain: ____________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Certification of Brand Family and Units Sold Part 4: Certification of Escrow Account and Agreement NPM-US Page 2 of 4 The NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account, pursuant to N.J.S.A. 52:4D-1 et. seq. Name of Financial Institution (Escrow Agent) Mailing Address City Phone Contact Person Escrow Account Number New Jersey Sub-Account Number State Fax Contact E-Mail Total amount held in this account for the State of New Jersey Zip Code $ Are funds held for the benefit of the State of New Jersey in any account other than that listed above? If you answered "yes," write the total amount of all funds that are being held in any account for the benefit of the State of New Jersey, including the amount listed above. 9 Yes $ 9 No Has the Qualified Escrow Agreement been approved by the Attorney General? Attach an executed copy of your current escrow agreement whether or not it has already been approved by the Attorney General. 9 Yes 9 No Date of Agreement: __________________ Approval Date: __________________ Part 5: Worksheet for Cigarettes Sold During Liability Year Total of RYO Ounces from Part 3 RYO Stick Calculation (Divide RYO Ounces by .09) Total of Cigarette Sticks from Part 3 Total NPM Sales (Add RYO Stick Calculation to Total of Cigarette Sticks) Refer to Worksheet at left to calculate the number of individual cigarettes bearing New Jersey cigarette tax stamps, including rollyour-own tobacco (.09 ounces = 1 cigarette), which were manufactured by this manufacturer and sold in New Jersey during this reporting period. Certification Year 2013 Worksheet is for sales made in 2012: 2013 Other: _____________ Please convert pounds to ounces before using this worksheet. (Multiply by 16 for each pound.) Use the rates listed below to figure the appropriate deposit amount. Part 6: Deposit Amount For the liability year 2012 the rate per cigarette is . . . . . . . . . . ..........................$ 0.0188482 For the 2012 liability period, the inflation adjustment percentage is........................ 54.42219% $0.0188482 x 1.4992446 = Escrow amount owed per stick, adjusted for inflation. Contact the New Jersey Office of the Attorney General for rates for previous years. 1 2 3 4 5 Enter the escrow amount owed per stick, adjusted by inflation. Write the amount of Total NPM Sales calculated in Part 5 of this worksheet. Multiply Line 1 by Line 2 and write down this number. This is the total amount to be paid into the escrow account for this liability year by the manufacturer identified in Part 2 of this worksheet. Enter the total amount paid into the escrow account for this liability year. Amount over/under-paid (Difference between Line 4 and Line 3.) Provide explanation if not zero. ___________________________________________________________________________________________ ___________________________________________________________________________________________ 1 2 3 $ 0.0291058 4 $ 5 $ Note: Attach a copy of your receipt or other proof of deposit from your financial institution. American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Certification of Brand Family and Units Sold Part 7: Certification of Deposits, Withdrawals and Transfers NPM-US Page 3 of 4 Attach separate page for each sub-account. The NPM certifies the following to be a complete record of each deposit and withdrawal or transfer which has occurred from any and all accounts containing funds held for the benefit of the State of New Jersey. Report ending balances of all such accounts, even where no deposits or withdrawals occurred. Attach copies of records of the financial institution documenting any account activity. New Jersey Sub-Account Number Name of Financial Institution (Escrow Agent) Date Deposit Amount Withdrawal or Transfer Amount Explanation for Withdrawal or Transfer Column Totals Deposits $ $ Withdrawals/Transfers $ Ending Balance for this New Jersey Sub-Account American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Certification of Brand Family
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