Kentucky Non Participating Manufacturer Quarterly Certification Form

2018 Kentucky Non - Participating Manufacturer Quarterly Certification Form 1.Name: 2.Street address: 3.City, state, country, ZIP: 4.Telephone number: 5.Electronic mail address: Part 2: Liability Year/Quarter (Sales quar ter) 6. The liability year for this certificate is: 2018, Q Part 3: Units Sold 7. Number of individual cigarettes and RYO sold by the manufacturer identified above during the liability quarter subject to Kentucky excise tax as follows (by brand; nine h undredths (.09) of an ounce of RYO tobacco counts as 1 stick): A) Total sticks: Part 4: Deposit Amount Fo r the liability year 2007 and after, the base rate per cigarette is... 0.0188482 8.The appropriate rate for the liability year as adjusted for inflation* is at least: 8. $ 0.0347539 9.Multiply Line 8 by total of Part 3, Line 7, and write the amount here: ( Total Escrow Deposit due for the quarter ): 9. Note : Attach a copy of your receipt or other proof of deposit from your financial institution as well as a copy of the escrow agreement between you and the institution if you have not previously provided one or if amended. American LegalNet, Inc. www.FormsWorkFlow.com 2018 Kentucky Non - Participating Manufacturer Quarterly Certification Form Part 5: Financial Institution 10.Name: 11.Street address: 12.City, state, country, ZIP: 13.Escrow account number: 14.Total amo unt held in this account after current deposit: $ 15.Escrow A gent: 16.Phone Number: Part 6: Authorized Signature Under penalties of perjury, I state that, to the best of my knowledge, all of the information contained in this certificate is true and accurate. I also certify that the financial instrument required by Kentucky law is still in effect and valid. (This document must be signed and dated by an authorized notary public .) Print the name of authorized agent Title Sworn to and subscribed before me this day of , 2018 Signature of Notary Public Signature of authorized agent Date City/ State: My commission expires: //, *The cumulative inflation adjustment is calculated pursuant to Exhibit C of the MSA. Quarterly deposits are due 30 days after the end of the calendar quarter. This form is due 10 days after the deposit due date. Send to: Kentucky Office of Atto rney General, 700 Capitol Avenue, Suite 118, Frankfort, KY 40601, (Attention: Michael Plumley, Assistant Attorney General). American LegalNet, Inc. www.FormsWorkFlow.com