Form Tt-19-Npm - Tobacco Product Manufacturer Certification For Non-Participating Manufacturers Page 8

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Part 9: Qualified Escrow Fund
A. Financial Institution
Agent:
Institution:
Address:
Phone:
Fax:
Email:
Account:
Commonwealth of Virginia (Sub)Account:
• The current Escrow Agreement and any amendments thereto must be approved by the
Attorney General of Virginia before the Tobacco Product Manufacturer can be certified. A
copy of the current Escrow Agreement and any amendments thereto must be attached to
this Certification.
B. Escrow History for the Commonwealth of Virginia (Sub)Account
(attach supplemental pages if needed)
DATE
DEPOSIT
WITHDRAWAL
BALANCE
TOTALS
• The appropriate Compliance Certification for calculation of escrow due or Certification of No
Sales must accompany this Certification. (See instructions for this form)
• A current account ledger and a statement from the Escrow Agent verifying all current calendar
year transaction records for the Commonwealth of Virginia (sub)account must be attached to
the Certification. Any withdrawal must comply with Va. Code § 3.1-336.1(B).
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