Utah State Tax Commission 210 N 1950 W • Salt Lake City, UT 84134 • www.tax.utah.gov TC-554 Nonparticipating Manufacturer’s (NPM’s) Quarterly Escrow Payment Affidavit 1. Manufacturer Information Rev. 2/11 2. Reporting Period Company name FEIN Year: Mailing address 2011 City Phone State Fax ZIP Code Other:_____ Country Quarter: Web address Jan-Mar Apr-Jun Mailing address City Phone State Fax ZIP Code Country Email (due Oct. 31) (due Jan. 31) Affidavit type: Original Name of person completing this form Title (due Aug. 1) Oct-Dec Title (due May 2) Jul-Sep Designated contact Amended Phone number 3. Brand Sales A. Brand Family B. Type C. Sticks Sold D. Ounces Sold (check one) this period (cigarettes) this period (RYO) E. Conversion F. RYO Stick (RYO to sticks) Equivalent Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Cigarette RYO ÷ .09 = Totals: 3C Use addendum sheets as necessary Enter this amount on Part 5, line 1 3F Enter this amount on Part 5, line 2 American LegalNet, Inc. www.FormsWorkFlow.com 4. Certification and Agreement TC-554_2.ai The NPM certifies that it has established and continues to maintain a fully-funded, qualified escrow account, pursuant to Utah Code §59-22-202(6). Name of financial institution (escrow agent) Contact person Mailing address Contact e-mail City State Phone Fax ZIP Code Escrow account number Utah sub-account number Total amount held in this account for the State of Utah $ 5. Escrow Deposit 1. Total cigarette sticks (from 3C) ........................................................................................................... 1 2. Total RYO stick equivalent (from 3F)................................................................................................... 2 3. Total NPM sales (add line 1 and line 2) .............................................................................................. 3 4. Rate per unit (adjusted for inflation)* .................................................................................................. 4 .0282581 5. Required escrow deposit (multiply line 3 by line 4).......................................................................... 5 6. Total amount actually paid into the escrow account for this period ..................................................... 6 Attach a copy of your receipt or other proof of deposit from your financial institution. 7. Amount (over)/under paid (subtract line 6 from line 5)........................................................................ 7 Provide explanation if not zero. * Contact the Utah State Tax Commission, Miscellaneous Tax Section at (801) 297-3533 for rates for previous years. 6. Manufacturer Certification Under penalty of falsification, I declare that, to the best of my knowledge, all of the information contained in this Affidavit and any attached documentation is true and accurate. Print name: NPM Authorized Designee Title Signature of NPM Authorized Designee Date Subscribed and sworn to before me this date: Signature of Notary Public This document must be signed and dated by a Notary Public. County Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com TC-554_3.ai Quarterly Escrow Payment Affidavit Instructions Mailing Form Instructions Mail the completed Affidavit and required documentation to: Utah State Tax Commission Miscellaneous Tax Section 210 N 1950 W Salt Lake City, UT 84134-3500 Part 1: Manufacturer Information Provide all information regarding the company, designated contact, and name of person completing the form. The designated contact is the person who will receive mailings from the Tax Commission regarding quarterly payments. and a copy to: Utah Attorney General’s Office Tobacco Contact Assistant Attorney General 160 E 300 S, 5th floor P.O. Box 140857 Salt Lake City, UT 84114-0857 Part 2: Reporting Period • Check the correct reporting year. • Check the correct quarter. • Check whether this is an original or amended affidavit. Before mailing, check to make sure you have included: • This form, all pages Part 3: Brand Sales • Proof of deposit for Part 5 If you had more brand sales than lines in Part 3, use addendum sheets, form TC-554-add. • Any addendum pages for Part 3 Column A Brand Family: Provide the brand name, which includes brand styles (menthol, 100's, etc.). Do not list each style in Part 3. Get forms online: tax.utah.gov If a brand is sold as both cigarettes and RYO, use a separate line for each. General Information For information or help with this form, call the Miscellaneous Tax Section at (801) 297-3533. Who Must File NPMs selling cigarettes in Utah must certify their quarterly installment deposits into an escrow account. See Utah Code §59-14-602(3)(c). Column B Type: Check whether the product is cigarettes or RYO. Column C Sticks Sold: For each Brand Family, enter the number of cigarettes the company sold in Utah during this period, either directly or indirectly through any distributor, retailer or similar agent. Add all the amounts in Column C and enter the total in box 3C (at the bottom of Part 3). If you use addendum sheets, be sure the total in 3C includes the Column C amounts from Part 3 and each addendum sheet. Annual Reconciliation If your quarterly payments do not meet your annual liability, you must make a reconciliation payment by April 30 of the following year. To report previously unreported sales, amend the Quarterly Escrow Payment Affidavit for the last quarter of the year. Check the “Amended” box in Part 2 of the form. Use the worksheet below to determine if you owe additional escrow: Column D Ounces Sold: For each Brand Family, enter the total RYO ounces sold in Utah during this period, either directly or indirectly through a distributor, retailer, or similar agent. Column F Annual Reconciliation Worksheet 1. Sticks sold during the year (cigarettes) _______ 3. Total sticks (add lines 1 and 2) Add all the amounts in Column F and enter the total in box 3F (at the bottom of Part 3). If you use addendum sheets, be sure the total in 3F includes the Column F amounts from Part 3 and each addendum sheet. _______ 2. RYO stick equivalents sold during the year _______ 4. Rate per unit (inflation-adjusted for 2011) 5. Required escrow for year (line 3 x line 4) Quarterly payments: RYO Stick Equivalent: Divide the total ounces in column D by .09 and enter the result in column F. .0282581 $ _______ a. $ _______ b. $ _______ c. $ _______ d. $ _______ 6. Total quarterly payments (add lines a – d) $ _______ 7. Difference (line 5 minus line 6) Part 4: Certification and Agreement Provide all information regarding the financial institution (escrow agent) where the NPM has established a qualified escrow account. See Utah Code §59-22-202(6). The total amount held for the State of Utah is the amount held in the Utah sub-account as of the date of certification. $ ______ _ Part 5: Escrow Deposit If line 7 is greater than zero, make a reconciliation escrow payment and file an amended affidavit by April 30. Line 1 Enter the total cigarette sticks sold for all brand families from Part 3, box 3C. American LegalNet, Inc. www.FormsWorkFlow.com TC-554_4.ai Line 2 Enter the total RYO stick equivalents for all brand families from Part 3, box 3F. Line 5 Multiply line 3 by line 4 and enter total required escrow deposit. Line 6 Enter the amount actually paid into the escrow account for this period. Attach proof of deposit(s) from your financial institution. Proof must include the account number of the Utah sub-account, the date of deposit, and the amount of deposit. Proof may be a receipt or a letter from your financial institution. Line 7 Subtract line 6 from line 5. If the result is not zero, provide an explanation. Part 6: Manufacturer Certification The authorized designee must be an officer, principal, director or other authorized representative of the manufacturer. The authorized designee’s name and title must be legibly printed and the signature must be notarized. __________________ _ _ _ _ If you need an accomodation under the Americans with Disablities Act, contact the Tax Commission at 801-297-3811 or TDD 801-297-2020. Please allow three working days for a response. American LegalNet, Inc. www.FormsWorkFlow.com