Non-Participating Manufacturer Quarterly Certification Form. This is a Arkansas form and can be use in Attorney General Statewide.
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