Non-Participating Manufacturer Certification Of Escrow Compliance - Office Of The Kansas Attorney General

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O
K
A
G
FFICE OF THE
ANSAS
TTORNEY
ENERAL
120 SW 10th Ave, 2nd Floor • Topeka, Kansas 66612-1597
Tel 785-368-6289 • Fax 785-296-5010
Email tobacco@ag.ks.gov • Web
N
-P
M
ON
ARTICIPATING
ANUFACTURER
C
E
C
ERTIFICATION OF
SCROW
OMPLIANCE
Please complete and return this form after receiving your quarterly notice.
T
C
& E
Q
YPE OF
ERTIFICATION
SCROW
UARTER
_____ I
_____ A
NITIAL
MENDMENT
For sales reported during year ____________
(January – March)
(July – September)
_____ 1
Q
_____ 3
Q
ST
UARTER
RD
UARTER
(April – June)
(October – December)
_____ 2
Q
_____ 4
Q
ND
UARTER
TH
UARTER
M
I
ANUFACTURER
NFORMATION
M
____________________________________________________________
ANUFACTURER
M
A
____________________________________________________________
AILING
DDRESS
____________________________________________________________
S
A
____________________________________________________________
TREET
DDRESS
____________________________________________________________
P
N
________________________ F
N
_______________________
HONE
UMBER
AX
UMBER
E
A
____________________________________________________________
MAIL
DDRESS
W
____________________________________________________________
EBSITE
Non-Participating Manufacturer Certification of Escrow Compliance
Revised February 2017
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