Delaware > Statewide > Attorney General > Tobacco Litigation
Quarterly Certificate Of Nonparticipating Tobacco Product Manufacturer Compliance - Delaware
| Quarterly Certificate Of Nonparticipating Tobacco Product Manufacturer Compliance Form. This is a Delaware form and can be used in Tobacco Litigation Attorney General Statewide . |
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2013 Delaware Quarterly Certificate of Nonparticipating Tobacco Product Manufacturer Compliance 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/Quarter 6. The liability year for this certificate is: 2013, Q___ Part 3: Units Sold 7. Number of individual cigarettes sold by the manufacturer identified above during the liability quarter bearing Delaware cigarette tax stamps is as follows(list amounts by brand): 1)_____________________________2)____________________________ 3)________________________________________ 4) ____________________________ 5)_____________________________Total sticks: _______________________________ Part 4: Deposit Amount For the liability year 2013, the base rate per cigarette is ...... $0.0188482 8. The appropriate rate for the liability year as adjusted for inflation* is: 8. 0.0 266359 9. Multiply Line 8 by total of Line 7, and write the amount (Total Escrow Payment due for the quarter): 9. __________________________ This is your total amount due to be paid into the qualified escrow account. Note: Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the institution if you have not previously provided one or if it has been amended. Part 5: Financial institution 10. Name: _____________________________________________________________________________________________ 11. Street address: _______________________________________________________________________________________ 12. City, state, country, ZIP: _______________________________________________________________________________ 13. Escrow account number _________________________________ 14. Total amount held in this account after current deposit: $_________________________________ 15. Escrow agent: ________________________________________ 16. Phone Number: ______________________________ Part 6: Authorized 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. _______________________________________________ Sworn to and subscribed before me Print the name of authorized agent Title this ____ day of _________________, 20___ _________________________________________________ Signature of Notary Public City / State: _______________________________________ My commission expires ________/__________/__________ * The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. _______________________________________________ Signature of authorized agent Date Quarterly deposits are due 30 days after the end of the calendar quarter. This form is due 10 days after the deposit due date and may be sent to: State of Delaware, Office of Attorney General, Department of Justice, Carvel Office Building, 820 N. French Street, 6th FL, Wilmington, DE 19801, (Attention: Thomas E. Brown, Deputy Attorney General). American LegalNet, Inc. www.FormsWorkFlow.com
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