Form 1783 - South Dakota Tobacco Product Manufacturer Complementary Legislation Certification Page 6

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PART: 6 NON-PARTICIPATING MANUFACTURER REGISTERED AGENT
A.
Check one below:
The Non-participating Manufacturer identified in Part 1 is registered to do business in South Dakota
The Non-participating Manufacturer identified in Part 1 has appointed and continues to engage the
following agent located in South Dakota
A current (dated this year) letter from the registered agent accepting this appointment must
be attached
Name of Registered Agent
Address
City/State/Zip
Telephone Number
Fax Number
PART 7: NON-PARTICIPATING MANUFACTURER QUALIFIED ESCROW ACCOUNT
A.
Escrow Account Information
The Non-participating Manufacturer identified in Part 1 has established and continues to maintain the following qualified
escrow fund under SDCL 10-50B.
Name of Financial Institution
Address
City/State/Zip
Contact Name/Title
Telephone Number
Fax Number
Escrow Account Number
South Dakota Sub-Account Number
If a Non-participating Manufacturer has NOT filed a current Escrow Agreement, including any
amendments or attachments, with the Attorney General for approval, the Escrow Agreement and
amendments or attachments must be filed with the Department of Revenue with this Complementary
Legislation Certification.
A Non-participating Manufacturer must file quarterly Certificates of Compliance with the Attorney
General’s Office pursuant to SDCL ch. 10-50B, setting forth the escrow calculation and the deposit for
each quarter of the year.
B.
Escrow Deposit/Withdrawal History for the State of South Dakota (attach additional sheets if necessary):
Withdrawals must comply with SDCL ch. 10-50B and verification of compliance must be provided.
Date
Deposit
Withdrawal
Balance
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Total:
Total:
Total:
$0.00
$0.00
$0.00
6

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