Form 5302 - Annual Escrow Compliance Certificate And Affidavit (Non-Participating Manufacturers)

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Missouri Department of Revenue

FORM

Taxation Division

5302

P.O. BOX 811 Jefferson City MO 65105-0811

ANNUAL ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT

(REV. 01-2013)

(NON-PARTICIPATING MANUFACTURERS)

PART 1: SALES YEAR

_________________

SALES YEAR

PART 2: MANUFACTURER IDENTIFICATION

FEDERAL I.D. NUMBER

COMPANY NAME

__ __ __ __ __ __ __ __ __

MAILING ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

__ __ __ __ __

PHYSICAL ADDRESS

CITY

STATE

COUNTRY

ZIP CODE

__ __ __ __ __

TELEPHONE NUMBER

__ __ __ __ __ __ __ __ __ __ __ __ __ __

FAX NUMBER

__ __ __ __ __ __ __ __ __ __ __ __ __ __

E-MAIL ADDRESS

PART 3: UNITS SOLD (THE NUMBER OF INDIVIDUAL CIGARETTES SOLD IN THE STATE OR OUNCES OF RYO DIVIDED BY .09)

(((

NUMBER OF UNITS (STICKS) SOLD

CIGARETTES (C) or

BRAND FAMILY (Do not separately list styles within a brand family

DURING THE SALES YEAR

(FOR RYO, STICKS = OUNCES ÷ .O9)

RYO (RYO)

such as Regular, Menthol, Light, 100s, etc.)*

TOTAL UNITS SOLD:

*By including a brand family in its certification, a Non-Participating Manufacturer affirms that the brand family listed is deemed to be its cigarettes for escrow

purposes for the year indicated in Part 1 of this form. However, the Director of Revenue retains the discretion to determine whether the brand family

constitutes the cigarettes of another tobacco product manufacturer.

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DOR-5302 (01-2013)