Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Non-Participating Manufacturer Quarterly Certification Form. This is a Arkansas form and can be use in Attorney General Statewide.
Loading PDF...
Tags: Non-Participating Manufacturer Quarterly Certification Form, Arkansas Statewide, Attorney General
STATE OF ARKANSAS
Ɣ
-
NON-PARTICIPATING
MANUFACTURER QUARTERLY
CERTIFICATION FORM
CERTIFICATION TYPE:
Original
CERTIFICATION YEAR
201
*Due Within 20 Days of Conclusion of Each
Calendar Quarter
Amended
REPORTING PERIOD:
First Quarter
Second Quarter
Third Quarter
Fourth Quarter
BUSINESS INFORMATION:
Business Name:
Address:
State:
Telephone:
Contact Person:
City:
Zip Code:
Email:
BRAND SALES:
Brand Family:
Units Sold During Calendar Quarter:
Total Number of Units Sold:
ĺTo determine the number of units sold for roll-your-own tobacco products, divide the total number of ounces of each brand family
by .09. For example, 18 ounces of roll-your-own is 200 units sold (18 ÷ .09 = 200).
QUALIFIED ESCROW ACCOUNT:
Financial Institution:
Address:
State:
Email:
Arkansas Sub-Account Number:
Representative’s Name:
City:
Zip Code:
Escrow Account Number:
Date of Escrow Agreement:
ESCROW OBLIGATION FOR SALES PERIOD:
Total number of units sold in Arkansas during calendar quarter:
Statutory rate per cigarette ($0.0188482), as adjusted for inflation:
Multiply units sold by the adjusted statutory rate per cigarette:
Amount Deposited for Calendar Quarter:
$0.02
ĺ An account statement or letter from the escrow agent must be included with this Certification Form. This account statement or
letter must indicate: (1) the amount deposited, as indicated above and (2) the date of deposit.
ĺ The total amount to be deposited into the Qualified Escrow may need to be recalculated at the time of the Annual Certification.
American LegalNet, Inc.
www.FormsWorkFlow.com
ADDITIONAL INFORMATION:
Is the registered agent identified on the company’s most recent Annual
Certification still the registered agent for the NPM?
Is the escrow agreement provided with the company’s most recent Annual
Certification still accurate, in force, and unchanged?
Yes
No
Yes
No
If you answer to either of the preceding questions was “no,” please explain.
Explanation:
SIGNATURE:
Authorized Designee:
Designee Signature:
Title:
Date:
NOTARY:
Subscribed and Sworn Before Me on this Date:
Signature of Notary Public:
City or County of:
My Commission Expires:
MAIL THE COMPLETED CERTIFICATION FORM TO:
Office of the Arkansas Attorney General
ĺCertification Forms, including attachments, must be received within 20 days
ATTN: Tobacco Division
of the conclusion of each calendar quarter.
ĺCertification Forms will be returned and left unprocessed unless all fields are
323 Center Street, Suite 200
completed and all required attachments have been received.
Little Rock, Arkansas 72201
American LegalNet, Inc.
www.FormsWorkFlow.com
