Missouri Certificate of Compliance Nonparticipating Manufacturer Escrow Payment Revised 01/2009 Section 1 Non-Participating Manufacturer Information 1. Company Name: 2. Contact Name: 3. Street Address: 4. City, State, Country, Zip: 5. Telephone Number: 6. Fax Number: 7. Email Address: Section 2 Financial Institution Information 1. Institution Name: 2. Contact Name: 3. Address: 4. Telephone Number: 5. Fax Number: 6. Email Address: Section 3 Escrow Information 1. Date Escrow was Established: 2. Account Number: A copy of the fully executed escrow agreement between the Non-Participating Manufacturer and the escrow account Institution must accompany the return of this completed form. Section 4 Deposit Amount Use the rates listed below to figure the appropriate deposit amount. Escrow Due/Sales Year: $.0094241 per unit sold after July 1,1999 (effective date of the Act) plus inflation of 3%; For 2000: $.0104712 plus inflation of 6.48841% per unit sold; For 2001: $.0136125 plus inflation of 9.68306% per unit sold; For 2002: $.0136125 plus inflation of 12.97355% per unit sold; For 2003: $.0167539 plus inflation of 16.36276% per unit sold; For 2004: $.0167539 plus inflation of 20.15102% per unit sold; For 2005: $.0167539 plus inflation of 24.25497% per unit sold; For 2006: $.0167539 plus inflation of 27.98262% per unit sold; For 2007: $.0188482 plus inflation of 33.20594% per unit sold; For 2008: $.0188482 plus inflation of 37.20212% per unit sold for a total of $.0258601 per unit sold. Number of Units Sold in 2008: Escrow Deposit for State of Missouri for 2008 sales: Escrow Balance as of 04/15/09: A statement from the Financial Institution indicating the proof of deposit and current balance must accompany this form American LegalNet, Inc. www.FormsWorkflow.com Section 5 Registered Agent If the Manufacturer has not registered with the Missouri Secretary of State to do business in the state of Missouri, the following should be completed. Registered Agent/Appointed for service of process Agent Name: Company: Local Address: Phone/Fax: E-mail: Section 6 Brand Family Identification Brand Family Brand Name Units Sold 2008 *Other Manufacturer (Attach Additional Pages if Necessary) Identify other manufacturers including, but not limited to, any other current or previous fabricators of any brands or brand families listed above. * Identification of Other Manufacturer's) Address Brand/Brand Family Name Year Section 7 Signature I herby certify, to the best of my ability and under penalty of perjury that the information above is true and accurate. I understand that public officials in the State of Missouri will rely on the veracity of the information I am providing. Name (Print) Title Date Signature Subscribed and sworn to before me, a notary public, this___ day of __________, 200_ (Seal) Notary Public My Commission Expires Send To: Missouri Attorney General P.O. Box 899 207 W High St Jefferson City, MO 65102 573-751-3321 American LegalNet, Inc. www.FormsWorkflow.com