Form 510 - Tobacco Product Manufacturer Certificate Of Compliance
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Alaska
510
Tobacco Product Manufacturer
Certificate of Compliance
Authority: AS 43.50 & 45.53
Part I: Tobacco Product Manufacturer Identification
Name of Manufacturer
Phone Number
Mailing Address
Fax Number
City
State
Zip Code
Email Address
Name of Person Completing Report
Title
Contact Phone Number
Check if this is an initial Certificate of Compliance (see instructions)
The Tobacco Product Manufacturer identified above is, as of the date of certification:
(initial one)
A Participating Manufacturer under the Tobacco Master Settlement Agreement
(Participating manufactureres must complete Part II, Columns A & B of Part III, Part V and Part VI)
A Non-participating Tobacco Product Manufacturer in full compliance with AS 45.53.
(Non-participating manufacturers must complete Parts II, III, IV, V and VI and attach a copy of the escrow agreement, including all amendments
thereto, executed with the Financial Institution identified in Part IV)
Part II: Sales Year
(see instructions)
The year of sales for this Certificate of Compliance:
(Please complete a separate certification for each year of sales)
Part III: Brand Family Identification
(attach additional sheets if necessary)
C. Units Sold in
D. Units Sold
E. Other Manufacturer of (A) in Preceding Year
AK Preceding
in AK Current
A. Brand Family
B. Brand Name
(name & address)
Year
Year
Total Units Sold....................................................
510
Mail to: Alaska Department of Revenue,
,
0405-510 Revised 04/10/13 - page 1
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