Certificate Of Compliance By Non-Participating Manufacturer Regarding Escrow Payment - Alabama Department Of Revenue
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TOB: NPM-ESC CERT
LABAMA
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P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Certificate of Compliance by Non-Participating Manufacturer
Regarding Escrow Payment
P RT 1 – M NUF CTURER’S IDENTIFIC TION
Name: _____________________________________________________________________ FEIN:
Address: _____________________________________________________________________________________________________
City: ____________________________ State: ___________________ Zip/Postal Code: _____________ Country: ________________
Telephone Number: (_______)_______________________
FAX Number: (_______)_______________________
P RT 2 – S LES YE R/QU RTER
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2
3
4
The Year and/or Quarter (if applicable) of Sales for this Certificate of Compliance is: ________
Year
Quarter (check quarter, if applicable)
(Complete a separate certificate for each year or quarter of sales. If you have been required to make deposits and certifications quar-
terly, quarters are divided as follows: January 1- March 31; April 1- June 30; July 1- September 30; and October 1- December 31.)
P RT 3 – UNITS SOLD
Number of individual cigarettes and “roll-your-own” tobacco sold in Alabama (directly or indirectly) by the
Manufacturer identified above during the sales year or quarter: (See instructions for details.) __________________________________
P RT 4 – ESCROW R TES
ND P YMENTS
For the sales year: (Use and adjust the rates listed below to figure the appropriate total deposit amount.)
1999 – The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0094241
2000 – The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.0104712
2001 - 2002 – The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . 0.0136125
2003 - 2006 – The rate per cigarette is . . . . . . . . . . . . . . . . . . . . . . . 0.0167539
2007 and thereafter – The rate per cigarette is . . . . . . . . . . . . . . . . . 0.0188482
The appropriate DEPOSIT SUBTOTAL is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
(Multiply units in Part 3 by the appropriate rate in Part 4)
The appropriate INFLATION ADJUSTMENT for the sales year is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
(Please refer generally to Exhibit C of the tobacco Master Settlement Agreement for calculation of the cumulative adjustment for infla-
tion applicable to each year’s escrow payment. For payments due April 15 multiply the deposit subtotal by the appropriate rate listed
below to figure the appropriate total deposit amount.)
1999 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
3% (0.030000000)
2000 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . . 6.4884136% (0.064884136)
2001 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . . 9.6830623% (0.096830623)
2002 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
12.97355% (0.129735500)
2003 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . . 16.3627565% (0.163627565)
2004 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
20.15103% (0.201510300)
2005 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
24.25497% (0.242549700)
2006 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
27.98262% (0.279826200)
2007 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
33.20594% (0.332059400)
2008 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
37.20212% (0.372021200)
2009 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
41.31818% (0.413181800)
2010 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
45.55773% (0.455577300)
2011 – Inflation rate is . . . . . . . . . . . . . . . . . . . . . .
49.92446% (0.499244600)
If you have been required to make a quarterly deposit and certification for the 2012 sales year, the estimated inflation rate is
54.42219%. Adjustments may be made requiring additional deposits or credits if this estimated rate is not correct. Please refer to the
NPM instructions for information regarding escrow deposit and certification dates.
TOTAL AMOUNT that has been paid into the Qualified escrow fund by the Manufacturer identified
above for the sales year or quarter. (Add deposit subtotal and the inflation adjustment amount.) . . . . . . . $_______________________
NOTE: For the initial deposit, attach a copy of your executed escrow agreement and for all deposits attach copies of your
receipt or other proof of deposit from your financial institution and copies, if any, of amendments to your escrow agreement.
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