Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance Page 2
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5Tobacco Product Manufacturer Certificate of Compliance
Part IV: Non-participating Manufacturer Certification
Are you registered to do business in Alaska
Yes
No
If yes, provide Alaska Corporation File #_____________ and Alaska Business License #______________
If no, you are required to appoint a resident agent for service of process and complete item A. below.
A. Registered Agent/Approved Agent for Service of Process
Agent Name
Telephone Number
Company Name
Fax Number
Mailing Address
City
State
Zip Code
Email Address
B. Qualified Escrow Fund
1. Cigarettes Sold In Alaska.
Enter the number of cigarettes sold in Alaska during the sales year.
(From Part III, Column D.)…………………………………………………………………………………………………………
Escrow Rates and Payments
A
B
C
Sales Year
Escrow Rate
Inflation Adj.
Adjusted Rate
1999
The rate per cigarette is……………
0.0094241
0.0002827
0.0097068
2000
The rate per cigarette is……………
0.0104712
0.0006794
0.0111506
2001
The rate per cigarette is……………
0.0136125
0.0013181
0.0149306
2002
The rate per cigarette is……………
0.0136125
0.0017660
0.0153785
2003
The rate per cigarette is……………
0.0167539
0.0027414
0.0194953
2004
The rate per cigarette is……………
0.0167539
0.0033761
0.0201300
2005
The rate per cigarette is……………
0.0167539
0.0040637
0.0208176
2006
The rate per cigarette is……………
0.0167539
0.0046882
0.0214421
2007
The rate per cigarette is……………
0.0188482
0.0062587
0.0251069
2008
The rate per cigarette is……………
0.0188482
0.0070119
0.0258601
2009
The rate per cigarette is……………
0.0188482
0.0077877
0.0266359
2. Escrow payment required.
Multiply the number of cigarettes sold on line 1 by the appropriate rate in
column C
. (Refer generally to Exhibit C of the Tobacco Master Settlement Agreement for calculation of the
$
cumulative adjustment for inflation applicable to each year's escrow payment.)……………………………………………
C. Financial Institution Certification
(To be completed by Authorized Agent of Financial Institution where escrow account was established.)
Representative Name
Telephone Number
Name of Institution
Fax Number
Mailing Address
City
State
Zip Code
Escrow Account Number
State Account Number
Email Address
Amount deposited into the qualified escrow account for the sales year identified in Part II………………$
$
Balance as of _________________ in qualified escrow account for the benefit of the State of Alaska……………
Date
Form 04-510 (Rev 03/10)
Page 2 of 5
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