Looking for a South Dakota Attorney General Forms And Templates? Download it for free!

Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - South Dakota Office Of The Attorney General

SOUTH DAKOTA Certificate of Compliance

2011 Sales Reporting Period: Quarter 4

Non-Participating Manufacturer Escrow Payment

Plus Outstanding 2011 Inflation Adj.

South Dakota Codified Law Ch. 10-50B

Deposit Due: April 15, 2012

Part 1: Manufacturer's Identification

Name: __________________________________________________________________________________________________

Address:________________________________________________________________________________________________

Phone: _______________________________________________

Fax: ___________________________________________

List of Brand families:_____________________________________________________________________________________

"Brand families" is defined as: all styles of cigarettes and roll your own tobacco sold under the same trade mark and

differentiated from one another by means of additional modifiers or descriptors, and any brand name (alone or in conjunction

with any other word), trademark, logo, symbol, motto, selling message, recognizable pattern of colors, or any other indicia of

product identification identical, similar to, or identifiable with a previously known brand of cigarettes or roll your own tobacco.

Part 2: Units Sold

Number of individual cigarettes and "roll-your-own" tobacco units (0.09 oz = 1 unit) sold by the Manufacturer

identified above during Quarter 4 of 2011: ______________________

The calendar year is divided into the following quarters: January 1

to March 31

(Quarter 1); April 1

to June 30

(Quarter 2);

July 1

to September 30

(Quarter 3); and October 1

to December 31

(Quarter 4).

Part 3: Escrow Rates and Payments

For the sales year 2011, the rate per cigarette is . . . . . . . . $0.0188482

Part 4: Escrow Deposit Due Without Inflation Adjustment

The appropriate deposit subtotal is $ _________________ (Part 2 x Part 3)

Part 5: Inflation Adjustment

The inflation adjustment for sales year 2011 is 49.92446 percent.

$_____________________ (Part 4 x 0.4992446)

Part 6: Escrow Deposit Paid

The total amount that has been paid into the qualified escrow fund by the Manufacturer identified above for sales

in Quarter 4 of year 2011 is $ __________________________ (Part 4 + Part 5)

Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - South Dakota Office Of The Attorney General