Tobacco Product Manufacturer Certificate Of Compliance Form - 2010 Page 2
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4P RT 3 – NON-P RTICIP TING M NUF CTURER CERTIFIC TION
A. Registered Agent/Approved Agent for Service of Process
Agent Name: _________________________________________________________________________________________________
Company: ____________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
City: __________________________________________ State: ___________________________ Zip Code: _____________________
Telephone Number: (_______)_____________________________
FAX Number: (_______)________________________________
NOTE: Telephone number and fax number must be Alabama numbers.
E-mail Address: _______________________________________________________________________________________________
Registered with the Secretary of State as a foreign corporation or business entity?
Yes
No
If Yes, Date Registered: __________________________. Is the registration current as of the date of certification?
Yes
No
B. Qualified Escrow Fund – Financial Institution
Name of Institution: ____________________________________________________________________________________________
Address: _____________________________________________________________________________________________________
City: __________________________________________ State: ___________________________ Zip Code: _____________________
Representative Name: ____________________________________________ Telephone Number: (_______)___________________
Escrow Account Number: _______________________________
State Account Number: __________________________________
C. Escrow Deposit/Withdrawal History for Alabama – Attach NPM Certificate of Escrow Deposit
WITHDRAWAL 2
DATE
DEPOSIT
BALANCE
$
$
$
(Initial certification should include a complete history. Annual certifications thereafter should be for the applicable sales year.)
P RT 4 – EXECUTION BY
UTHORIZED
GENT
Under penalty of perjury, I state that the statements contained in this certification are true, correct and complete. This certificate is made
to induce the State of Alabama to place the above-named manufacturer and its brand family on the Directory of Compliant Tobacco
Products and Manufacturers in Alabama. I further certify that the above-named manufacturer is in full compliance with Title 6, Chapter
12, of the Alabama Code.
Name of Authorized Agent (Print): ________________________________________________ Title: ___________________________
Signature of Authorized Agent: ___________________________________________________ Date: ___________________________
Subscribed and sworn to before me on this date: ___________________________________
Signature of Notary Public: _____________________________________________________
Notary for the State of: _____________________________ City or County of: ____________________________________________
My Commission expires: _______________________________________________________
Mail the completed TPM Certificate of Compliance to:
Alabama Department of Revenue
Attn: Commissioner of Revenue
P. O. Box 327555
Montgomery, AL 36132
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Withdrawals must comply with Alabama Code §6-12-3. Verification of compliance must be provided.
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