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Certificate Of Compliance - Maryland
| Certificate Of Compliance Form. This is a Maryland form and can be used in Tobacco Enforcement Attorney General Statewide . |
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CERTIFICATE OF COMPLIANCE With MD Code Ann., Bus. Reg. §§16-401 to 16-403 Calendar Year 2011 For definitions of terms, please refer to Md Code Ann., Bus. Reg. §16-402 1. Nonparticipating Manufacturer's Identification Name: Address: _______________________________________________________ _______________________________________________________ _______________________________________________________ Phone: 2. ______________________ Fax: ___________________________ Status as Tobacco Product Manufacturer Selling in Maryland In 2011, the manufacturer was a tobacco product manufacturer that sold cigarettes to consumers in Maryland, directly or through a distributor, retailer, or similar intermediary. Yes ___________________ No__________________ If the answer is no, please enter 0 for the number of units sold in Part 3. If the answer is yes, you are obligated to set up a qualifying escrow account, and deposit the appropriate funds. 3. Units sold In calendar year 2011, the manufacturer sold the following number of individual cigarettes and "roll-your-own" tobacco in Maryland: _____________________________________ 4. Escrow rate and payment The unadjusted escrow rate for 2011 is $0.0188482. The inflation adjustment multiplier for 2011 is 49.92446%. The escrow rate adjusted for inflation is $0.0282581. American LegalNet, Inc. www.FormsWorkFlow.com Number of cigarettes sold (from #3): Inflation-adjusted escrow rate (from #4): Total amount to be deposited in escrow: 5. Financial Institution Name of Institution: Address of Institution: ___________________________ x $0.0282581 $__________________________ ____________________________________________ ____________________________________________ ____________________________________________ Phone Number: ____________________________________________ Account Number: ____________________________________________ Date Account Opened: ____________________________________________ Total Amount Held for State of Maryland: $_______________________________ Documentation 6. If this is your initial deposit, attach a copy of your executed escrow agreement, and copies of amendments, if any, to your escrow agreement. For all deposits, attach copies of your receipt or other proof of deposit from your financial institution. 7. Certification I certify that the above information is true and correct. Signature of Authorized Agent: Name of Authorized Agent: Title of Authorized Agent: Date: 8. ______________________________________ ______________________________________ ______________________________________ ______________________________________ Mail this certificate of compliance to: David S. Lapp, Chief Counsel Tobacco Enforcement Unit Office of the Attorney General of Maryland 200 St. Paul Place, 20 th Floor Baltimore, Maryland 21202 American LegalNet, Inc. www.FormsWorkFlow.com
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