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Non-Participating Manufacturer Certification Of Quarterly Escrow Compliance - Tennessee
| Non-Participating Manufacturer Certification Of Quarterly 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 Certification of Quarterly Escrow Compliance Review instructions prior to completion. PART 1: Escrow Certification Period 1st Quarter (Jan.-March) 2nd Quarter (April-June) 3rd Quarter (July-Sept.) 4 Quarter (Oct.-Dec.) th Year Original Certification Amended Certification* *Date of Original *Please see instructions for deadlines.* PART 2: Tobacco Product Manufacturer Identification Company Name: Mailing Address: City: Country: State: Web/Email Address: Zip Code: Name and title of person completing form: FEIN: PART 3: Designated Contact Name: Company/Firm: Mailing Address: City: Country: Web/Email Address: ***This Office will only disclose information regarding the company, escrow account, compliance status, or directory status with those listed in this affidavit.*** Title: State: Phone: Fax: Zip Code: 1 American LegalNet, Inc. www.FormsWorkFlow.com Amended [ ] (Check if amended.) Original Total NPM Sales: State of Tennessee Non-Participating Manufacturer 2012 Certification of Quarterly Escrow Compliance PART 4: Worksheet for Tobacco Products units sold in the State of Tennessee by licensed Tennessee Wholesalers, including licensed Tennessee wholesalers located outside Tennessee Brand Name Number of Cigarettes sold Ounces of Roll-Your-Own Tobacco sold Name & Address of the Wholesaler, Distributor or Retailer to whom each product was sold. TOTALS Add cigarette and RYO totals. Enter total NPM sales in Part 5, Line 1. 2 American LegalNet, Inc. www.FormsWorkFlow.com State of Tennessee Non-Participating Manufacturer 2012 Certification of Quarterly Escrow Compliance PART 5: Deposit Amount Step 1: Total NPM sales (part 4) Step 2: The appropriate rate per cigarette for the reporting year 2012 (Contact Tobacco Enforcement Division for previous rates). Step 3: Multiply Total NPM sales in Line 1 by Line 2. Step 4: Multiply Line 3 by the inflation adjustment percentage. For the 2012 certification period, use the preliminary inflation adjustment of 54.4221938%. This is the total amount to be paid into escrow for this quarter. 1 2 3 .0188482 .0188482 0.00 X 4 1.544221938 1.544221938 $0.00 ****Proof of deposit or receipt is required from the financial institution at which the escrow account exists.**** PART 6: Escrow Account Information and Certification Name of Financial Institution or Escrow Agent: Mailing Address: City: Phone: Contact Person: Contact Email: Escrow Account Number: Tennessee Sub-Account Number: State State: Fax: Zip Code: of Tennessee Date of Escrow Agreement: Nonparticipating Manufacturer Date of Last Amendment to Escrow Agreement: Affidavit of Quarterly Escrow Payment Total amount held in this account for Tennessee: $ 3 American LegalNet, Inc. www.FormsWorkFlow.com PART 7: Manufacturer Certification *Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this Affidavit and any attached documents are true and accurate.* NPM Designee (PRINT) Title Signature of NPM Designee Date Subscribed and sworn to before me this date Signature of Notary Public Commission Expires: *By submitting this affidavit, 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.* Mail to: Tennessee Attorney General Tobacco Enforcement Division P.O. Box 20207 Nashville, TN 37202-0207 **All requested documents and information must be submitted with this certification; certifications without the required documents and information will be returned unprocessed.** 4 American LegalNet, Inc. www.FormsWorkFlow.com
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