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Form 510 Product Manufacturer Certificate of Compliance Fill In
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(From Part III Column D) Check if this is an initial Certificate of Compliance (see instructions) If no please submit your registration to ATF before proceeding If no you are required to appoint a resident agent for service of process and complete item A below If yes please attach a copy of your ATF registration If yes provide Alaska Corporation File # and Alaska Business License # (initial one) (name & address) (Non participating manufacturers must complete Parts II III IV V and VI and attach a copy of the escrow agreement including all amendments (Participating manufactureres must complete Part II Columns A & B of Part III Part V and Part VI) (This certificate of compliance must also be signed and dated by an authorized notary public) (To be completed by Authorized Agent of Financial Institution where the escrow account was established) 0 0006794 0 0013181 0 0017660 0 0027414 0 0033761 0 0040637 0 0046882 0 0062587 0 0070119 0 0077877 0 0085868 0 0094099 0 0102576 0 0104712 0 0111506 0 0136125 0 0149306 0 0153785 0 0167539 0 0167539 0 0188482 0 0188482 0 0188482 0 0194953 0 0201300 0 0208176 0 0214421 0 0251069 0 0258601 0 0266359 0 0274350 0 0282581 0 0291058 1 Are you registered with ATF? Yes No 1 Cigarettes Sold In Alaska Enter the number of cigarettes sold in Alaska during the sales year 2 Are you registered to do business in Alaska? Yes No 2 Escrow payment required Multiply the number of cigarettes sold on line 1 by the appropriate rate in 510510 5105100405 510 Rev 04/10/13 page 2 5105100405 510 Revised 04/10/13 page 1 A Brand Family A Non participating Tobacco Product Manufacturer in full compliance with AS 45 53 A Participating Manufacturer under the Tobacco Master Settlement Agreement A Qualified Escrow Fund Adjusted Rate adjustment for inflation applicable to each year s escrow payment) $ Agent Name AK Preceding Alaska Amount deposited into the qualified escrow account for the sales year identified in Part II $ applicable sales year Authority: AS 43 50 & 45 53 B Brand Name B Financial Institution Certification Balance Balance as of in qualified escrow account for the benefit of the State of Alaska $ C Escrow Deposit/Withdrawal History for Alaska C Units Sold in Certificate of Compliance Certificate of Compliance City or County of column C (Refer generally to Exhibit C of the Tobacco Master Settlement Agreement for calculation of the cumulative Company Name Contact Phone Number D Units Sold Deposit E Other Manufacturer of (A) in Preceding Year Email Address Email Address Escrow Account Number Escrow Rate Escrow Rates and Payments Fax Number Fax Number in AK Current Inflation Adj institution where the escrow account is maintained) Mail to: Alaska Department of Revenue Mailing Address Mailing Address My Commission expires Name of Institution Name of Manufacturer Name of Person Completing Report Note: Initial certification should include a complete history of activity in the escrow account Annual certifications thereafter should be for the Part I: Tobacco Product Manufacturer Identification Part II: Sales Year (see instructions) Part III: Brand Family Identification (attach additional sheets if necessary) Part IV: Non participating Manufacturer Certification Part V: PACT Act Registration (must be completed by both PMs and NPMs) Part VI: Signatures (Nonparticipating manufacturers must obtain a signature from an authorized agent of the financial Phone Number Phone Number Printed Name of Authorized Agent of Financial Institution Printed Name of Authorized Agent of Manufacturer Representative Name Sales Year Signature of Authorized Agent of Financial Institution Signature of Authorized Agent of Manufacturer Signature of Notary Public State State State Account Number Subscribed and sworn to before me on this date The rate per cigarette is The rate per cigarette is The rate per cigarette is The rate per cigarette is The rate per cigarette is The rate per cigarette is The rate per cigarette is The Tobacco Product Manufacturer identified above is as of the date of certification: The year of sales for this Certificate of Compliance: (Please complete a separate certification for each year of sales) thereto executed with the Financial Institution identified in Part IV) Title Title Tobacco Product Manufacturer Tobacco Product Manufacturer Total Units Sold Under penalty of perjury I state that to the best of my knowledge all of the information contained in the Certificate of Compliance is true and accurate Withdrawal You must retain all supporting documents substantiating this Certificate of Compliance for a period of five years Zip Code Zip Code