Form Tob: Npm-Esc Cert - Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment - 2011 Page 2

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P RT 5 – FIN NCI L INSTITUTION

Name of Institution: ____________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

City: __________________________________________ State: ___________________________ Zip Code: _____________________

Escrow Account Number: __________________________________ State Account Number: _________________________________

P RT 6 – SIGN TURE

Under penalty of perjury, I state that, to the best knowledge, all of the information contained in this certificate of compliance is true and

accurate.

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 this Certificate of Compliance to:

Alabama Department of Revenue

Attn: Commissioner of Revenue

P. O. Box 327555

Montgomery, AL 36132-7555

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