Certificate Of Compliance Non-Participating Manufacturer Escrow Payment - South Dakota Office Of The Attorney General - 2011


SOUTH DAKOTA Certificate of Compliance
2011 Sales Reporting Period
Non-Participating Manufacturer Escrow Payment
Quarter 1
South Dakota Codified Law Ch. 10-50B
Deposit Due: May 31, 2011
Part 1: Manufacturer's Identification
Name: __________________________________________________________________________________________________
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 1 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 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: Estimated Inflation Adjustment
The estimated inflation adjustment for Quarter 1 of sales year 2011 is 49.92446%.
$_____________________ (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 1 of year 2011 is $ __________________________ (Part 4 + Part 5)


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