Form Dr 0231 - Tobacco Product Manufacturer Certification Page 4
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4PART 4. NON-PARTICIPATING MANUFACTURER CERTIFICATION
A. Registered Agent / Approved Agent for service of process
Agent Name
Company
Address
Address
Phone
FAX
Email
Has the Agent for Service of Process been approved by the Attorney General?
Yes
No
By Whom
Approval Date
B. Qualified Escrow Fund – Financial Institution
Name of Institution
Address
Representative Name
Phone
Escrow Account Number
State Account Number
Has the Qualified Escrow Agreement been approved by the Attorney General?
Yes
No
By Whom
Approval Date
C. Escrow Deposit/Withdrawal History for Colorado
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DATE
DEPOSIT
WITHDRAWAL
BALANCE
PART 5. SIGNATURE
Under penalty of perjury, I state that the information contained in this Certification is true and accurate.
Authorized Designee
Title
Signature of Authorized
Date
Subscribed and sworn to before me on this date
Signature of Notary Public
City or County of
My Commission expires
Mail a completed Certificate of Compliance to each office listed below:
Colorado Department of Revenue
Office of the Attorney General
1375 Sherman St Rm 208
Consumer Protection Section
Denver CO 80261
Tobacco Settlement Enforcement
303-205-8211 Extension 6860
1525 Sherman St 5th Flr
Denver CO 80203
303-866-5079
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Withdrawals must comply with C.R.S. 39-28-203 (II). Verification of compliance must be provided.
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