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2008 Quarterly Certificate Of Escrow Deposit Form. This is a Montana form and can be use in Department Of Justice Statewide.
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MONTANA DEPARTMENT OF JUSTICE
2008 Quarterly Certificate of Escrow Deposit
Part 1: Non-Participating Manufacturer (NPM) Identification
Company Name:
Physical Address:
Mailing Address (if different):
Contact Person Name and Title:
Telephone Number:
FAX:
E-mail Address:
Name of retailer(s)/wholesaler(s) that sells your cigarettes or RYO in Montana and brand(s)
sold:
Part 2: Quarter Being Reported
The sales year for this certificate is the calendar year 2008. The quarter being reported is
(check one):
January 1, 2008 - March 31, 2008
April 1, 2008 - June 30, 2008
July 1, 2008 - September 30, 2008
October 1, 2008 - December 31, 2008
Part 3: Units Sold for the Quarter Indicated
Indicate the number of individual cigarettes and units of “roll-your-own” tobacco sold by the
manufacturer (whether directly or through a distributor, retailer, or similar intermediary or
intermediaries) for the 2008 quarter indicated above and produce any and all
documentation of the sale or transfer of cigarettes or RYO into Montana:
A. __________________________
Part 4: Deposit Amount
The deposit amount for 2008 is $.0258601 per unit sold. * B.
$.0258601
Multiply line A by line B to calculate the total deposit due.
This amount must be deposited in the Montana subaccount of the manufacturer’s qualified escrow
account within 30 days after the end of the quarter indicated above.
Mont. Code Ann. § 16-11-403(2)(a) requires payments to be “adjusted for inflation.” Mont. Code Ann. § 16-11-402(1)
defines “adjusted for inflation” as “increased in accordance with the formula for inflation adjustment set forth in Exhibit C
to the Master Settlement Agreement. Each year, this formula increases 3% or the actual inflation rate, whichever is greater.
Because the actual inflation rate cannot be determined until the end of 2008, tobacco product manufacturers required to
make quarterly escrow payments will be required, in their quarterly escrow payments, to deposit an amount that has been
cumulatively adjusted for inflation by 3%. When the inflation rate for 2008 has been determined, manufacturers will be
advised and then have until April 15, 2009, to deposit any additional money, if necessary, to satisfy the actual inflation
amount under the Act. The 2007 inflation rate, increased by 3%, is 37.20212. Multiplying the 2008 base escrow deposit
amount $.0188482, by the inflation rate, 37.20212%, equals the cumulative inflation adjustment amount of $.0070119.
Adding the base escrow deposit amount, $.0188482, to the cumulative inflation adjustment amount, $.0070119, equals
$.0258601.
*
Montana Department of Justice
2008 Quarterly Certificate of Escrow Deposit
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Part 5: Financial Institution
Name of Financial Institution:
Escrow Agent Contact Name and Title:
Mailing Address:
Telephone Number:
Escrow Account Number:
FAX:
Montana Subaccount Number:_______________
Attach a copy of the financial institution’s receipt or other proof of deposit of the proper escrow
payment.
Part 6: Certification
The above-named NPM certifies that (initial all four):
It has previously submitted a Montana Certificate of Escrow Deposit to Attorney
General’s Office. Date submitted:
Its qualified escrow fund complies with Mont. Code Ann. § 16-11-403;
Any escrow funds held or to be held in its qualified escrow fund on behalf of the
State of Montana are or will be held in a separate segregated account, separate and apart from
escrow funds held on behalf of any other beneficiary; and
There is no security interest that has been granted in or has attached or is otherwise
applicable to any escrow funds held or to be held in the above-named Non-Participating
Manufacturer’s qualified escrow fund on behalf of the State of Montana.
Part 7: Authorized Designee and Representation
This document must be signed and dated by an authorized notary public as follows:
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this 2008 Quarterly Certificate of Escrow Deposit, including attachments are
true, correct, accurate and complete in every particular and that I am a person authorized to
bind the above-named NPM making this Certification either under the laws of the State of
Montana or of the jurisdiction where the manufacturer resides or is organized. Any violation
of these requirements is a basis for removal of the above-named NPM and its brand families
from the Tobacco Product Directory.
Authorized Designee:
Signature of Designee:
Title:
Date:
SUBSCRIBED AND SWORN TO before me on this date:
Signature of Notary Public:
City or County of:
Printed Name of Notary Public:
My Commission expires:
Seal:
Mail the completed Certificate to:
Mr. Mark McLaverty
Montana Attorney General's Office
215 North Sanders
P.O. Box 201401
Helena, MT 59620-1401
Montana Department of Justice
AND
Mr. Lee Baerlocher
Customer Service Center Division
Department of Revenue
P.O. Box 5805
Helena, MT 59604-5805
2008 Quarterly Certificate of Escrow Deposit
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