Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance Page 3
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5Tobacco Product Manufacturer Certificate of Compliance
C. Escrow Deposit/Withdrawal History for Alaska
Deposit
Withdrawal
Balance
Date
Note: Initial certification should include a complete history of activity in the escrow account. Annual certifications thereafter should be for
the applicable sales year.
Part V. Signatures
(Nonparticipating manufacturers must obtain a signature from an authorized agent of the financial institution where the
escrow account is maintained.)
Under penalty of perjury, I state that, to the best of my knowledge, all of the information contained in this Certificate of Compliance is true and accurate.
(This certificate of compliance must also be signed and dated by an authorized notary public.)
Printed Name of Authorized Agent of Manufacturer
Title
Signature of Authorized Agent of Manufacturer
Date
Printed Name of Authorized Agent of Financial Institution
Title
Signature of Authorized Agent of Financial Institution
Date
Subscribed and sworn to before me on this date
Signature of Notary Public
City or County of
My Commission expires
You must retain all supporting documents substantiating this Certificate of Compliance for a period of five years.
Form 04-510 (Rev 03/10)
Page 3 of 5
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