Form Dr 0237 - Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment Page 2
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3Certificate of Compliance by Non-Participating
Manufacturer Regarding Escrow Payment
Part 1: Manufacturer’s Identification
Name
Address
Phone
Fax
Web Site Address
Email
Part 2: Sales Year
The year of sales for the Certificate of Compliance is:__________(Complete a separate certificate for each year of sales.)
Part 3: Units Sold
(Attach Additional Sheets, if necessary)
Indicate with an asterisk (*) those brands that will not be sold in 2013. The brands indicated with an asterisk (*) will be
removed from the Colorado Certified Brands Directory the month following the receipt of the Certificate of Compliance for the
2012 year of sales.
A. Brand Family
B. Brand Name
C. Cigarette or RYO
C. Units Sold
D. Manufacturer
*
Part 4: Escrow Rates and Payments
For Sales Year:
Total units sold during sales year: _________________________________ (for RYO divide ounces sold by .09)
Documentation to support the “units sold,” including but not limited to invoices, spreadsheets and sales
statements, must be attached and filed with this Certificate of Compliance.
Escrow Rate: for sales year 2012, the rate per cigarette is $0.0188482.
Escrow deposit subtotal: $ __________________________________ (multiply total units sold by escrow rate)
Inflation adjustment: The appropriate inflation adjustment for sales year 2012 is 54.42219%. For payments due
April 15, 2013, multiply Escrow Deposit entered above by. $
.
Escrow deposit paid: The total amount that has been paid into the qualified escrow fund by the manufacturer identified
above for the sales year 2012 is $
(add deposit subtotal and inflation adjustment)
A copy of your executed Escrow Agreement and any amendment to the Escrow Agreement, a current escrow
account statement from the financial institution for the Colorado sub-account, and copies of your receipt or other
proof of deposit from your financial institution, must be attached and filed with this Certificate.
Note:
The state of Colorado will not process incomplete or illegible certifications.
Attach additional sheets as necessary to provide a complete response.
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