Non-Participating Manufacturer Certification Of Annual Escrow Compliance
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Non-Participating Manufacturer Certification Of Annual Escrow Compliance Form. This is a Tennessee form and can be use in Attorney General Statewide.
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State of Tennessee
Non-Participating Manufacturer
2010 Certification of Annual Escrow Compliance
Review instructions prior to completion.
Company Name:
Mailing Address:
City, State and Zip Code:
Country:
Phone no. ______________________________________
Web/Email Address:
Name and title of person completing form:
Total NPM units certified in 1st quarter: ________________________ Deposit___________________
Total NPM units certified in 2nd quarter: ________________________ Deposit___________________
Total NPM units certified in 3rd quarter: ________________________ Deposit___________________
Total NPM units certified in 4th quarter: ________________________ Deposit___________________
TOTAL NPM units for all quarters:___________________ Amount Deposited __________________
Step 1: Total NPM units sold for 2010 (convert RYO oz. by dividing by 0.09)
(Total sold during January through December 2010)
1
Step 2: The appropriate rate per cigarette for the reporting
year 2010 (Contact Tobacco Enforcement Division
for previous rates).
2
Step 3: Multiply Total NPM sales in Step 1 by Step 2.
3
Step 4: Multiply Step 3 by the inflation adjustment percentage of 45.55773.
4
Step 5: This is the total amount that should be held in escrow for 2010 sales.
5
Step 6: Subtract Step 5 from the amount that has been deposited for all
6
quarters in 2010. This is the additional amount that has been deposited
into escrow. Attach a letter from the bank or other proof of deposit.
X
0.0188482
X
1.4555773
_____________________
Under penalties of perjury, I declare that, to the best of my knowledge, all of the information contained in this
report and any attached documents are true and accurate.*
NPM Designee (PRINT)
Title
Signature of NPM Designee
Date
Mail this form to:
Tennessee Attorney General, Tobacco Enforcement Division, P.O. Box 20207, Nashville, TN 37202-0207
*By submitting this report, the NPM certifies that it has established, and continues to maintain, a fully funded,
qualified escrow account, as defined and regulated by the Tennessee Tobacco Manufacturers’ Escrow Fund Act of
1999, Tenn. Code Ann. § 47-31-101, et seq.
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