Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance

Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance - 2000

State of Alaska

Department of Revenue

Tax Division

550 W. Seventh Avenue, Suite 500

Anchorage, AK 99501

Tobacco Product Manufacturer

Certificate of Compliance

AS 45.53.040

Tobacco Product Manufacturer Certification

Business Name_________________________________________________________________

Address_______________________________________________________________________

The above named tobacco product manufacturer certifies that a qualified escrow account has been

established in accordance with AS 45.53.020(a)(2) with a financial institution that meets the

requirements of AS 45.53.020(c). The tobacco product manufacturer further certifies that for the

period June 3, 1999 through December 31, 1999, _______________(number) cigarettes were sold in

Alaska, either directly or through a distributor. Funds in the amount of $_________________ have

been deposited into said escrow account.

_________________________________________

___________________

_____________

(Signature of Authorized Agent of Tobacco

(Title)

(Date)

Product Manufacturer)

______________________________________________________________________________

Financial Institution Certification

The above named tobacco product manufacturer has, on this day, placed funds in the amount of

$__________________ into an escrow account established for the benefit of the State of Alaska and

other releasing parties in accordance with AS 45.53. In accordance with AS 45.53, interest or other

appreciation on such money shall accrue to the benefit of the tobacco product manufacturer. The fund’s

principal shall be released from escrow only under circumstances allowed in AS 45.53.020(b).

_________________________________________

___________________

_____________

(Signature of Authorized Agent of

(Title)

(Date)

Financial Institution)

______________________________________________________________________________

NOTE: You must attach a complete copy of the escrow agreement between the tobacco product

manufacturer and the institution in which the escrow account was established.

Form 04-510 (New 03/00)

Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance - 2000