Form Cg-30.2 - Information Regarding Escrow Payment - New York State Department Of Taxation And Finance

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CG-30.2
New York State Department of Taxation and Finance
Information Regarding Escrow Payment
Attachment to Form CG-30, Certification of
Tobacco Master Settlement Agreement Status
This form may only be used to report escrow funds for calendar year 2004. To report escrow funds for any other year,
contact the Tax Department for the correct form.
Legal name
Date
Federal employer identification number (FEIN)
In accordance with the provisions of Public Health Law, section 1399-pp, the above tobacco product manufacturer is a
non-participating manufacturer in the tobacco master settlement agreement and has established any required qualified
escrow fund for calendar year 2004, as described below.
1 Number of individual cigarettes (sticks), by complete brand name, manufactured by you, and sold during calendar year 2004 in New York State
Complete brand name*
Number of cigarettes (sticks)
Total number of cigarettes (sticks) .........................................................................................
1.
*Be sure the complete brand names of the cigarettes are listed, including the following
:
(attach additional sheets, if necessary)
• filtered or unfiltered
• descriptive information such as menthol or slim
• size (such as, regular, king, 100’s, etc.)
• other information as necessary to identify the product (such as country of origin and manufacturer name)
2 Escrow rate for calendar year 2004 (This rate includes both the rate and the inflation
adjustment required by Public Health Law section 1399-pp (2).) ............................................................ 2.
0.0201300
$
3 Amount paid into the qualified escrow fund for calendar year 2004
3.
$
(multiply the total from line 1 by line 2) ............
4
Financial institution’s name
Address of financial institution
Escrow account number
Total cumulative amount held for New York State
$

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