Name of Manufacturer Phone Number Mailing Address City State Name of Person Completing Report Zip Code Email Address Title Contact Phone Number ompliance (see instructions) T (initial one) A Participating Manufacturer under the Tobacco Master Settlement Agreement A Non-participating Tobacco Product Manufacturer in full compliance with AS 45.53. Part II: Sales Year (see instructions) The year of sales (attach additional sheets if necessary) A. B. C. Units Sold in AK Preceding Year D. Units Sold in AK Current Year E. Other Manufacturer of (A) in Preceding Year Total Units Sold.................................................... Mail to: ALASKA DEPARTMENT OF REVENUE TAX DIVISION 550 W SEVENTH STE 500 ANCHORAGE AK 99501-3555 0405-510 Revised 0 /12 - page 1 American LegalNet, Inc. www.FormsWorkFlow.com 1. Cigarettes Sold In Alaska. Enter the number of cigarettes sold in Alaska during the sales year. ............................................................................................................................................ A Escrow Rate Sales Year B C 0.0097068 1999 The rate per cigarette is...................................... 0.0094241 0.0002827 2000 The rate per cigarette is...................................... 0.0104712 0.0006794 0.0111506 2001 The rate per cigarette is...................................... 0.0136125 0.0013181 0.0149306 2002 The rate per cigarette is...................................... 0.0136125 0.0017660 0.0153785 2003 The rate per cigarette is...................................... 0.0167539 0.0027414 0.0194953 2004 The rate per cigarette is...................................... 0.0167539 0.0033761 0.0201300 2005 The rate per cigarette is...................................... 0.0167539 0.0040637 0.0208176 2006 The rate per cigarette is...................................... 0.0167539 0.0046882 0.0214421 2007 The rate per cigarette is...................................... 0.0188482 0.0062587 0.0251069 2008 The rate per cigarette is...................................... 0.0188482 0.0070119 0.0258601 2009 The rate per cigarette is...................................... 0.0188482 0.0077877 0.0266359 2010 The rate per cigarette is...................................... 0.0188482 0.0085868 0.0274350 2011 The rate per cigarette is...................................... 0.0188482 0.0094099 0.0282581 Multiply the number of cigarettes sold on line 1 by the appropriate rate in column C. ................................................................................................ $ (To be completed by Authorized Agent of Financial Institution where the escrow account was established) Representative Name Phone Number Name of Institution Mailing Address City State Zip Code Escrow Account Number State Account Number Email Address .......................................... $ ............................... $ Date Date Deposit Withdrawal Balance applicable sales year. 0405-510 Revised 0 /12 - page 2 American LegalNet, Inc. www.FormsWorkFlow.com (must be completed by both PMs and NPMs) 1. Are you registered with ATF? Yes No 2. Are you registered to do business in Alaska? Yes No Agent Name Phone Number Company Name Mailing Address City State Zip Code Email Address Part VI: Signatures where the escrow account is maintained) Printed Name of Authorized Agent of Manufacturer Title Signature of Authorized Agent of Manufacturer Date Printed Name of Authorized Agent of Financial Institution Title Signature of Authorized Agent of Financial Institution Date Subscribed and sworn to before me on this date Signature of Notary Public City or County of 0405-510 Revised 0 /12 - page 3 American LegalNet, Inc. www.FormsWorkFlow.com