Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment Page 3
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3Certificate of Compliance
by Non-Participating Manufacturer Regarding Escrow Payment
GENERAL INFORMATION
State of Wisconsin
What is the definition of a tobacco
If you satisfy these requirements, you
When is this certificate of
product manufacturer?
must file this certificate of compliance
compliance due?
to report the units of cigarettes and/or
• Any
entity
that
manufactures
This certificate of compliance is to be
roll-your-own manufactured by you and
cigarettes anywhere, including roll-
filed on or before April 15th of the year
sold in the state of Wisconsin and pay
your-own, that such manufacturer
following the sales year.
the amount calculated into your quali-
intends to be sold in the United States
fied escrow fund.
For 2000, the sales year for tobacco
including cigarettes and/or roll-your-
products sold in Wisconsin is May 23,
own that are intended to be sold in the
What is a non-participating
2000 – December 31, 2000. After 2000,
United States through an importer;
manufacturer?
the sales year is a calendar year, from
• The first purchaser anywhere for
January 1 through December 31.
A non-participating manufacturer is any
resale in the United States of
tobacco product manufacturer who has
cigarettes, including roll-your-own,
When must I make my escrow
not signed onto the MSA .
manufactured anywhere that the
payment?
manufacturer does not intend to be
What is a qualified escrow fund?
You must deposit all escrow payments
sold in the United States; or
into your qualified escrow fund on or
A non-participating manufacturer that is
• A successor of any entity described
before April 15th of the year following
required to file this certificate of compli-
above.
the sales year. After you have made your
ance must establish a qualified escrow
deposit, forward a copy of your receipt
fund. This means an escrow arrange-
Who is required to file this
or other proof of deposit from your
ment with a U.S. federal or U.S.
certificate of compliance?
financial institution to the Office of the
state-chartered financial institution
Attorney General of the State of Wiscon-
having no affiliation with any tobacco
• Any tobacco product manufacturer
sin, along with this signed and notarized
product manufacturer and having assets
which:
certificate of compliance. In addition,
of at least $1,000,000,000, where such
(1) sells cigarettes and/or roll-your-
after you have made your initial deposit
arrangement (1) requires that the finan-
own within the state of Wisconsin
into the qualified escrow fund, forward
cial institution hold the escrowed funds’
a copy of the escrow agreement as
(whether directly or through any
principal for the benefit of the State of
executed. Finally, forward any amend-
distributor, retailer, or similar
Wisconsin (and possibly other “Releas-
intermediary) and
ments to the escrow agreement. This
ing Parties” as defined in the MSA) and
should include the escrow fund balance
(2) prohibits the non-participating manu-
(2) has not become a participating
as of March 31 of each year and if any
facturer from using, accessing, or
manufacturer in the tobacco
payments have been made from the
directing the use of the funds’ principal
Master Settlement Agreement
escrow fund and for what purpose.
except as consistent with 995.04(1)(f).
(MSA) executed on 11/23/98.
SPECIFIC INSTRUCTIONS
Part 1 – Manufacturer’s Identification
Part 4 – Escrow Rates and Payments
Part 5 – Financial Institution
Write your name, address, telephone
Multiply the units sold by the appropri-
Write the name and address of the
and fax number.
ate rate for the sales year and write the
financial institution holding your escrow
result as your subtotal. Calculate the
account. Include your escrow account
Part 2 – Sales Year
appropriate
inflation
adjustment
number. Also write the total cumulative
according to Exhibit C of the Tobacco
amount currently in your escrow account
Write the sales year.
Master Settlement Agreement (go to
for the benefit of Wisconsin.
) and enter the amount.
Part 3 – Units Sold
Add the subtotal and the inflation adjust-
Part 6 – Signature
Write the number of individual cigarettes
ment amount to arrive at the total deposit
An authorized notary public must also
and the amount of “roll-your-own”
to be paid into your qualified escrow ac-
sign and date this Certificate of
tobacco [.09 ounces (oz.) constitutes
count for Wisconsin for the applicable
Compliance.
one cigarette] manufactured by you and
sales year.
sold during the sales year in Wisconsin.
This should include a listing of the
cigarette and/or roll-your-own brands
that have been sold into Wisconsin as
detailed on your itemized sales report.
Complete a certificate for each year you are required to file an escrow payment for Wisconsin.
This certificate is available on the Wisconsin Department of Revenue’s web site at
under Forms > Excise > Tobacco Master Settlement Agreement (MSA).
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CTP-130i (R. 3-07)
Wisconsin Department of Revenue
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