Form 55b - Tobacco Product Manufacturer'S Certification - 2017 Page 8
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10Part 7: Nonparticipating Manufacturer Qualified Escrow Account
A. Qualified Escrow Fund Information
The nonparticipating manufacturer identified in Part 1 has established and continues to maintain the following qualified
escrow fund under Neb. Rev. Stat. § 69-2702(10).
Name of Financial Institution
Address
Representative Name and Title
Phone Number
Escrow Account Number
Nebraska Sub-Account Number
Has the Escrow Agreement been approved by the Attorney General?
Approval Date
YES
NO
If the escrow agreement has not been approved by the Attorney General, please attach a copy. If the escrow
agreement has been approved by the Attorney General, the tobacco product manufacturer identified in Part 1 hereby
swears said agreement is still in full force and effect without modification, or alternatively, a copy of any amendments to
said agreement made subsequent to Attorney General’s approval must be attached.
B. Escrow Deposit/Withdrawal History for Nebraska (attach additional sheets if necessary):
Date
Deposit
Withdrawal
Balance
Total:
Total:
Total:
Note: A nonparticipating manufacturer must also file a Nonparticipating Manufacturer Quarterly Escrow Certification with
the Attorney General’s Office pursuant to Neb. Rev. Stat. § 69-2703(2)(c) setting forth the escrow calculation and deposit
for each quarter of a year’s sales for eligibility to be listed on the Directory. A copy of the certificate may be obtained at
Part 8: Bond or Cash Equivalent for Nonparticipating Manufacturer
Does the nonparticipating manufacturer identified in Part 1 certify that it has a bond in place which meets
the requirements of Neb. Rev. Stat. § 69-2701.01?
Yes
c
No
c
If yes, submit a copy of the bond with this Certification.
Does the nonparticipating manufacturer identified in Part 1 certify that it has the cash equivalent of a
bond in place which meets the requirements of Neb. Rev. Stat. § 69-2707.01?
Yes
c
No
c
If yes, provide written proof of the cash equivalence from a financial institution.
Has the nonparticipating manufacturer identified in Part 1 submitted a Certification of Nonparticipating
Manufacturer Bond or Cash Equivalent form or a Quarterly Affirmance of Nonparticipating Manufacturer
Bond or Cash Equivalent form to the Nebraska Attorney General’s Office, and to the Nebraska
c
c
Department of Revenue, for each calendar quarter since the preceding year’s Form 55B submission?
Yes
No
If no, please explain.
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