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Missouri Certificate Of Compliance Nonparticipating Manufacturer Escrow Payment Form. This is a Missouri form and can be use in Department Of Revenue Statewide.
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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
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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
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