Non-Participating Manufacturer Certification Of Escrow Compliance - Office Of The Kansas Attorney General Page 2

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E
F
I
SCROW
UND
NFORMATION
F
I
_________________________________________________________
INANCIAL
NSTITUTION
C
N
_____________________________ T
______________________
ONTACT
AME
ITLE
M
A
_________________________________________________________
AILING
DDRESS
_________________________________________________________
P
N
________________________ F
N
_____________________
HONE
UMBER
AX
UMBER
E
A
_________________________________________________________
MAIL
DDRESS
P
E
A
N
__________________________________________
RIMARY
SCROW
CCOUNT
UMBER
K
S
-A
N
(
)
__________________________________________
ANSAS
UB
CCOUNT
UMBER
S
E
O
SCROW
BLIGATION
Calculate your escrow obligation owed for the quarter using the 2017 inflation-adjusted rate of
$0.0337416 per unit. Please refer to your official escrow notice to complete this portion.
1.
Enter cigarette units reported to Kansas in quarter
________________________
2.
Enter RYO ounces reported to Kansas in quarter
________________________
3.
Enter RYO units reported to Kansas in quarter
________________________
Divide line 2 by 0.09
4.
Enter total units reported to Kansas in quarter
________________________
Add line 1 to line 3
5.
Enter applicable rate per unit 2017: $0.0337416
________________________
6.
Enter escrow obligation due
________________________
Multiply line 4 by line 5
E
D
SCROW
EPOSIT
7.
Enter credit amount carried forward (if any)
________________________
Refer to your official notice
8.
Enter amount deposited for quarter
________________________
Do not include credit from line 7
9.
Enter credit amount remaining after
satisfaction of escrow obligation (if any)
________________________
Non-Participating Manufacturer Certification of Escrow Compliance
Revised February 2017
Page 2 of 3

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