Non-Participating Manufacturer Certification Of Quarterly Escrow Compliance

State of Tennessee Non-Participating Manufacturer Certification of Quarterly Escrow Compliance Review instructions prior to completion. PART 1: Escrow Certification Period 1st Quarter (Jan.-March) 2nd Quarter (April-June) 3rd Quarter (July-Sept.) 4th Quarter (Oct.-Dec.) Please see instructions for deadlines. Year ___________________ Original Certification Amended Certification Date of Original _______________ PART 2: Tobacco Product Manufacturer Identification Company Name: Mailing Address: City: Country: State: Web/E-mail Address: Zip Code: Name and title of person completing form: FEIN: PART 3: Designated Contact Name: Company/Firm: Mailing Address: City: Country: Web/E-mail Address: This Office will only disclose information regarding the company, escrow account, compliance status, or directory status with those listed in this affidavit. Revised January 2016 Page 1 of 4 Title: State: Phone: Fax: Zip Code: American LegalNet, Inc. www.FormsWorkFlow.com Quarterly Escrow Certification Form PART 4: Provide the following information regarding all brand families sold to Tennessee-licensed wholesalers, including wholesalers located outside of the state of Tennessee. Brand Name Number of Cigarettes sold Ounces of Roll-Your-Own Tobacco sold Name & Address of the Wholesaler, Distributor or Retailer to whom each product was sold. Name & Address of the Importer of Foreign Manufactured Products TOTALS Convert RYO by dividing total ounces by 0.09 then add that total to total cigarettes. Enter total NPM Units Sold in Part 5, Step 1. AMENDED [ ] (Check if marked amended on page 1.) Original Total NPM Sales: _________________________________________ Original Amount Deposited: _______________________________________ Additional deposit and date deposited: _______________________________ Additional deposit and date deposited: _______________________________ Additional deposit and date deposited: _______________________________ Additional deposit and date deposited: _______________________________ Additional deposit and date deposited: _______________________________ Revised January 2016 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Quarterly Escrow Certification Form PART 5: Deposit Amount Step 1: Total NPM units sold (part 4) (convert RYO by dividing by 0.09) Step 2: The appropriate rate per cigarette for the reporting year 2016 (Contact Tobacco Enforcement Division for previous rates). Step 3: Multiply Total NPM sales in Line 1 by Line 2. Step 4: Multiply Line 3 by the inflation adjustment percentage. For the 2016 certification period, use the preliminary inflation adjustment of 73.8035493%, based on the minimum 2016 inflation adjustment. This is the total amount to be paid into escrow for this quarter. 1 2 3 X .0188482 X 4 1.738035493 Proof of deposit or receipt is required from the financial institution at which the escrow account exists. PART 6: Escrow Account Information and Certification Name of Financial Institution or Escrow Agent: Mailing Address: City: Phone: Contact Person: Contact E-mail: Escrow Account Number: Tennessee Sub-Account Number: Date of Escrow Agreement: Date of Last Amendment to Escrow Agreement: Total amount held in all subaccounts for Tennessee: $ State: Fax: Zip Code: Revised January 2016 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Quarterly Escrow Certification Form PART 7: Manufacturer Certification Under penalty of perjury, I declare that all of the information contained in this document, and any attached documents, are true and correct. This document must be signed and dated by an authorized notary public. NPM Designee (PRINT) Title Signature of NPM Designee Date Subscribed and sworn to before me on this date Signature of Notary Public Commission Expires: By submitting this affidavit, 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. Mail to: Office of the Attorney General Revenue Section Tobacco Enforcement Division P.O. Box 20207 Nashville, TN 37202-0207 All requested documents and information must be submitted with this certification; certifications without the required documents and information will be returned unprocessed. Revised January 2016 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com