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Non-Participating Manufacturer Certification Of Annual Escrow Compliance - Tennessee
| Non-Participating Manufacturer Certification Of Annual Escrow Compliance Form. This is a Tennessee form and can be used in Tobacco Settlement Attorney General Statewide . |
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State of Tennessee Non-Participating Manufacturer 2010 Certification of Annual Escrow Compliance Review instructions prior to completion. Company Name: Mailing Address: City, State and Zip Code: Country: Web/Email Address: Name and title of person completing form: Total NPM units certified in 1st quarter: ________________________ Deposit___________________ Total NPM units certified in 2nd quarter: ________________________ Deposit___________________ Total NPM units certified in 3rd quarter: ________________________ Deposit___________________ Total NPM units certified in 4th quarter: ________________________ Deposit___________________ TOTAL NPM units for all quarters:___________________ Amount Deposited __________________ Step 1: Total NPM units sold for 2010 (convert RYO oz. by dividing by 0.09) (Total sold during January through December 2010) 1 Step 2: The appropriate rate per cigarette for the reporting year 2010 (Contact Tobacco Enforcement Division for previous rates). Step 3: Multiply Total NPM sales in Step 1 by Step 2. Step 4: Multiply Step 3 by the inflation adjustment percentage of 45.55773. Step 5: This is the total amount that should be held in escrow for 2010 sales. Phone no. ______________________________________ 2 3 4 5 X 0.0188482 X 1.4555773 Step 6: Subtract Step 5 from the amount that has been deposited for all 6 quarters in 2010. This is the additional amount that has been deposited into escrow. Attach a letter from the bank or other proof of deposit. _____________________ Under penalties of perjury, I declare that, to the best of my knowledge, all of the information contained in this report and any attached documents are true and accurate.* NPM Designee (PRINT) Title Signature of NPM Designee Date Mail this form to: Tennessee Attorney General, Tobacco Enforcement Division, P.O. Box 20207, Nashville, TN 37202-0207 *By submitting this report, the NPM certifies that it has established, and continues to maintain, a fully funded, qualified escrow account, as defined and regulated by the Tennessee Tobacco Manufacturers' Escrow Fund Act of 1999, Tenn. Code Ann. ยง 47-31-101, et seq. American LegalNet, Inc. www.FormsWorkFlow.com
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