Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance
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5State of Alaska
Alaska Department of Revenue
VOICE: 907.269.6620
Tobacco Product Manufacturer
Tax Division
FAX: 907.269.6644
Certificate of Compliance
550 W Seventh, Suite 500
Anchorage, AK 99501-3555
Authority: AS 43.50 & AS 45.53
Part I:
Tobacco Product Manufacturer Identification
Name of Manufacturer
Telephone Number
Mailing Address
Fax Number
City
State
Zip Code
Email Address
Name of Person Completing Report
Title
Contact Telephone Number
Check if this is an initial Certificate of Compliance (See instructions.)
The Tobacco Product Manufacturer identified above is, as of the date of certification:
(Initial One)
A Participating Manufacturer under the Tobacco Master Settlement Agreement
(Participating manufacturers must complete Part II, Columns A & B of Part III, and Part V.)
A Non-participating Tobacco Product Manufacturer in full compliance with AS 45.53.
(Non-participating manufacturers must complete Parts II, III, IV and V and attach a copy of the escrow agreement, including all
amendments thereto, executed with the Financial Institution identified in Part IV.)
Part II: Sales Year (see instructions)
The year of sales for this Certificate of Compliance:
(Please complete a separate certification for each year of sales)
Part III: Brand Family Identification
(Attach additional sheets if necessary.)
C. Units Sold
D. Units Sold
in AK
Preceding
in AK Current
A. Brand Family
B. Brand Name
Year
Year
E. Other Manufacturer of (A) in Preceding Year (name & address)
Total Units Sold……………………………………
Form 04-510 (Rev 03/10)
Page 1 of 5
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