Non-Participating Manufacturer Certification Of Annual Escrow Compliance

Sales Year: State of Tennessee Office of the Attorney General and Reporter Revenue Section Tobacco Enforcement Division Post Office Box 20207 Nashville, TN 37202-0207 Non-Participating Manufacturer Annual Certification of Escrow Compliance Please type or legibly print in permanent blue ink (This form may be filled out on-line. However, all signatures must be executed in permanent blue ink.) Part I: General Tobacco Product Manufacturer Information Applicant name: ___________________________________________________________________ Street Address: _____________________________________________________________________ City/State/Zip/Country: ______________________________________________________________ Mailing Address (if different from above):______________________________________________________ City/State/Zip/Country: ______________________________________________________________ Telephone number: ________________________ Facsimile number: __________________________ E-mail address: Website address: ____________________________________________________________________ Name of Person Completing Certificate: _________________________________________________ Title of Person Completing Certificate: __________________________________________________ Important Note: The Attorney General's Office will not process incomplete, unsigned or illegible certifications. Only official forms will be processed by the State. Revised January 2016 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com NPM Certification of Escrow Compliance 1. Identify by name, address, telephone number and e-mail address the attorney authorized to represent you regarding your Certificate of Escrow Compliance. (Attach additional sheets if necessary.) Name: Firm: Address: Phone Number: E-mail Address: 2. Identify by name, title, address, telephone number and e-mail address the person authorized to provide information to the State of Tennessee or receive information from the State of Tennessee regarding your Certificate of Escrow Compliance. (Attach additional sheets if necessary) Name: Title: Address: Phone Number: E-mail Address: 3. The Applicant is the Tobacco Product Manufacturer (i.e. fabricator) of the cigarettes listed in this Certificate which are intended to be sold in the United States, including cigarettes intended to be sold in the United States through an importer. Yes No The Applicant "[i]s the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere that the manufacturer does not intend to be sold in the United States." See Tenn. Code Ann. § 47-31-102 (9)(A)(ii). Yes No If the answer is "No" to question #3 or "Yes" to question #4, identify each manufacturer (i.e. fabricator), its plant street address, mailing address, contact person, telephone and facsimile phone numbers, and the relationship to the applicant. Identify the location of the transfer of ownership of Cigarettes and a copy of every agreement or contract between the applicant and fabricator. (Attach additional sheet(s), as necessary, to complete the response.) Yes No Applicant is a successor of any entity described in questions #3 or #4 above (i.e., manufacturer or first importer). Yes No If Applicant answered "No" to questions #4, #5 and #6 above, explain the basis for Applicant's claim that it is a Tobacco Product Manufacturer as defined by Tenn. Code Ann. § 47-31-102(9) and submit all documents to support Applicant's contention. (Attach additional sheet(s), as necessary, to provide a complete response.) Yes No 4. 5. 6. 7. Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com NPM Certification of Escrow Compliance Part II: Non-Participating Manufacturer Qualified Escrow Account Information Non-Participating Manufacturer Applicant certifies that as of the date of this Certificate, Applicant: 8. 9. Has established and continues to maintain a Qualified Escrow Fund. Yes No Has executed a Qualified Escrow Agreement that has been reviewed and approved by the Attorney General for the State of Tennessee: Yes No Please note the Model Escrow Agreement is available on the Tennessee Attorney General's website at http://www.tn.gov/attorneygeneral/tob/pdf/escrowagreement.pdf) 10. The Qualified Escrow Agreement submitted to the Attorney General for the State of Tennessee is identical to the one provided on the Tennessee Attorney General's Website? Yes No If you answered "No" to #10, please review and comply with the Instructions and Definitions. You are required to provide a redlined version of the Escrow Agreement for prior approval in writing by the Attorney General of the alterations. The redline copy must include double underlined markings of all additions and strike out markings of all deletions to the model Escrow Agreement. 11. Financial Institution information: Name of Institution: Representative Name/Title: Street Address: City/State/Zip Code: Escrow Acct. #: Sub-Acct. # For Tennessee: Telephone Number: Facsimile Number: E-mail Address of Bank Representative: Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com NPM Certification of Escrow Compliance 12. Escrow Calculation and Deposit for Sales in Tennessee for Calendar Year 2015: 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 (Cigarettes & RYO) during prior calendar year (Note: Convert RYO oz. by dividing by 0.09) (Total sold from January through December 2015.) Step 2: The appropriate rate per cigarette rate for the reporting year 2015 (Contact Tobacco Enforcement Division for prior year rates). 1 2 X 0.0188482 Step 3: Multiply Total NPM sales in Step 1 by Step 2. 3 Step 4: Multiply Step 3 by the inflation adjustment percentage for 2015: 4 X 1.687413010 Step 5: This is the total amount that should be held in escrow for 2015 sales. 5 Step 6: Amount already deposited in escrow (use ending balance from chart on page 5 of 7): 6 _____________________ Step 7: Subtract Step 6 (what has already been deposited for all quarters in 2015) from Step 5 (total amount of escrow due for 2015 sales). This is the additional amount t