Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance (Page 5 of 5) in pdf

Tobacco Product Manufacturer Certificate of Compliance - Instructions

Specific Instructions - Continued

Part IV: Non-Participating Manufacturer Certification

When to File the Certificate of Compliance. The initial Certificate

A. Registered Agent. An NPM must either be registered to do

of Compliance must be filed 30 days prior to selling cigarettes in

business in Alaska or appoint an agent in Alaska to act as the

Alaska in order for the TPM and its Brands and Brand Families to

manufacturer's agent for service of process.

If the NPM is

be approved for inclusion in the Directory.

All subsequent

registered to do business in Alaska, it must provide its Alaska

Certificates of Compliance must be filed by April 30 of each year

Corporation File Number and Alaska Business License Number.

following the Sales Year identified in Part II.

If not previously

These numbers are issued by the Alaska Department of

provided, a copy of the escrow agreement and any amendments

Community and Economic Development.

If the NPM is not

must be attached to this Certificate of Compliance to constitute a

registered to do business in Alaska, it must provide the name,

complete filing.

address, telephone number and email address for its registered

agent located in Alaska.

Where to File. File this form with the Commissioner of Revenue,

c/o Alaska Department of Revenue, Tax Division, 550 W. 7th

B. Qualified Escrow Fund. An NPM must provide the number

Avenue, Suite 500, Anchorage, Alaska 99501.

of cigarettes sold in Alaska during the sales year and calculate the

amount of the escrow payment, after inflation, required to be made

Questions. If you have any questions regarding this form or your

for the number of cigarettes sold in the state.

responsibilities under AS 43.50 and AS 45.53, contact the Alaska

Department of Revenue’s Anchorage office at (907) 269-6620.

C. Financial Institution. An NPM must identify the financial

institution where an escrow account for the benefit of the State of

Alaska was established. The financial institution must verify the

amount deposited into the escrow account for the sales year and

provide the balance in the escrow account as of the date the

certificate is completed.

D. Escrow Deposit/Withdrawal History for Alaska. An NPM

must provide a complete history of the escrow account at the time it

files its initial certificate of compliance.

Annual certifications

thereafter should only show deposits and withdrawals for the

applicable sales year.

Part V. Signatures. The certificate of compliance must be signed

by an authorized agent of the Tobacco Product Manufacturer

identified in Part I. The authorized agent's name and title must be

printed and the certificate must be signed in the presence of a

notary public. For certification by NPMs, the certificate must also

be signed by an authorized agent of the financial institution where

the escrow account has been established.

The agent of the

financial institution must sign the certificate in the presence of a

notary public.

Form 04-510 (Rev 03/10)

Page 5 of 5

Form 04-510 - Tobacco Product Manufacturer Certificate Of Compliance Page 5

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