Maryland > Statewide > Attorney General > Tobacco Enforcement
Quarterly Certificate Of Compliance Of Escrow Funding - Maryland
| Quarterly Certificate Of Compliance Of Escrow Funding Form. This is a Maryland form and can be used in Tobacco Enforcement Attorney General Statewide . |
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Maryland Quarterly Certificate of Compliance of Escrow Funding for 2012 Sales Calendar Year 2012 Please note: This form must be filed by nonparticipating manufacturers required to make quarterly escrow payments and certifications pursuant to COMAR 02.07.01. For instructions and definitions of terms used herein, please refer to Maryland Annotated Code, Business Regulation Article, §§16-401 et seq. & §§16-501 et seq. (available at http://www.oag.state.md.us/tobacco/statedirectory.htm). 1. Nonparticipating Manufacturer's identification Name: Address: _______________________________________________________ _______________________________________________________ _______________________________________________________ Phone: 2. _______________________ Fax: ________________________ Quarter being reported G G Jan. 1, 2012 March 31, 2012 July 1, 2012 Sept. 30, 2012 G G April 1, 2012 June 30, 2012 Oct. 1, 2012 Dec. 31, 2012 3. Units sold for quarter State the number of individual cigarettes and "roll-your-own" tobacco sold in Maryland in this quarter, whether sold directly or through a distributor, retailer or other intermediary, for the 2012 quarter indicated above: ____________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. Escrow rate and payment The escrow rate, adjusted for the minimum inflation rate, is $0.0291058. Number of cigarettes sold (from #3) ____________ to be multiplied by inflation-adjusted escrow rate of $0.0291058. Total amount to be deposited in escrow: $__________________________ 5. Financial Institution Name of Institution: Address of Institution: ____________________________________________ ____________________________________________ ____________________________________________ 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: 8. ____________________________________________ ____________________________________________ _______________________ Date: _____________ Mail this certificate of compliance to: David Lapp, Chief Counsel, Tobacco Enforcement Unit Office of the Attorney General of Maryland 200 St. Paul Place, 20 th Floor Baltimore, Maryland 21202 2 American LegalNet, Inc. www.FormsWorkFlow.com
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