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Certificate of Nonparticipating Manufacturer Regarding Annual Escrow Payment - Washington
| Certificate of Nonparticipating Manufacturer Regarding Annual Escrow Payment Form. This is a Washington form and can be used in Tobacco Suppliers And Manufacturers Office Of The Attorney General Statewide . |
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DUE APRIL 15, 2012 for 2011 Liability Year Washington Certificate of Nonparticipating Manufacturer Regarding Annual Escrow Payment Part 1: Manufacturer's identification 1. 2. 3. 4. 5. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ Telephone number: ___________________________________________________________________________________________ Electronic mail address:________________________________________________________________________________________ Part 2: Liability year Complete only one year of liability on this form. 6. The liability year for this certificate is: ____________________ Part 3: Units sold 7. Number of individual cigarettes and roll-your own sold by the manufacturer identified above during the liability year bearing Washington cigarette tax stamps is as follows: Part 7__________________________ 4: Deposit amount For Liability Year 2007 and thereafter, the yearly base rate per cigarette is 0.0188482. For Liability Year 2011, the yearly base rate and inflation adjustment rate per cigarette is 0.0282581. *8. Multiply Line 7 by 0.0282581 (includes 2011 yearly base rate and inflation adjustment) and enter the amount in line 8. This is the total amount due to be paid into the qualified escrow account. 8__________________________ Note: Attach a copy of your receipt or other proof of deposit from your financial institution. Part 5: Financial institution 9. Name: _____________________________________________________________________________________________________ Street address: _______________________________________________________________________________________________ City, state, country, ZIP: _______________________________________________________________________________________ 10. 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. _______________________________________________________ Print the name of authorized agent Title _______________________________________________________ Signature of authorized agent Date City / State: _____________________________________________ Subscribed and sworn to before me this ______ day of ____________________, 2012. ______________________________________________________ Signature of Notary Public My commission expires ___________/__________/____________ * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. This completed form must be filed with the Washington Attorney General's Office no later than April 15, 2012, for calendar year 2011. The form should be sent to either the following mailing address or if by courier, to our delivery address: Attorney General's Office Revenue Division PO Box 40123 Olympia, WA 98504-0123 Attorney General's Office Revenue Division 7141 Cleanwater Drive SW Tumwater, WA 98501 American LegalNet, Inc. www.FormsWorkFlow.com OR
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