Certificate Of Compliance Non Participating Manufacturer Escrow Payment
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Certificate Of Compliance Non Participating Manufacturer Escrow Payment Form. This is a North Dakota form and can be use in Office Of State Tax Commissioner Statewide.
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North Dakota Office of State Tax Commissioner
Certificate of Compliance
Non-Participating Manufacturer Escrow Payment
Manufacturer's Identification
Name:
Address:
Fax:
Phone:
Sales Year
The Year of Sales for this Certificate of Compliance is: (Complete a separate certificate for each year of sales)
Units Sold
Total number of individual cigarettes and "roll-your-own" tobacco sold by the Manufacturer identified above
during the
sales year is:
Brand Families:
Escrow Rates and Payments
For the sales year: (Use and adjust the rates listed below to figure the appropriate total deposit amount)
2000 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0104712
2001-2002 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0136125
2003-2006 - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0167539
2007 and thereafter - The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0188482
Inflation Adjustment
The appropriate deposit subtotal is $
.
For payments due April 15, 2008, multiply the deposit subtotal by 33.20594% (.3320594) and enter the result.
Escrow Deposit Paid
The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for the
sales year. $
(Add deposit subtotal and the inflation adjustment amount.)
Note: For the initial deposit, attach a copy of your executed escrow agreement and for all deposits attach copies
of your receipt or other proof of deposit from your financial institution and copies, if any, of amendments to your
escrow agreement.
Financial Institution
Name of Institution:
Address:
Escrow Acct. No.:
Sub-Acct. No.:
Total Amount Held
for the State
04-2008
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Signature
Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this Certificate of
Compliance is true and accurate. The Certificate of Compliance must also be signed and dated by an authorized notary
Name of Authorized Agent:
Title:
Signature of Authorized Agent:
Date:
Subscribed and sworn to before me on this date:
Signature of Notary Public:
My Commission Expires:
Mail this Certificate of Compliance to: Office of State Tax Commissioner
Tobacco Tax Section
600 E. Boulevard Ave. Dept. 127
Bismarck ND 58505-0599
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