Form 510 - Tobacco Product Manufacturer Certificate Of Compliance Page 2
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1
2
3Tobacco Product Manufacturer
510
Certificate of Compliance
Part IV: Non-participating Manufacturer Certification
A. Qualified Escrow Fund
1. Cigarettes Sold In Alaska.
Enter the number of cigarettes sold in Alaska during the sales year.
(From Part III, Column D) ............................................................................................................................................
Escrow Rates and Payments
A
B
C
Inflation Adj.
Escrow Rate
Adjusted Rate
Sales Year
0.0111506
2000
0.0104712
0.0006794
The rate per cigarette is......................................
0.0149306
2001
The rate per cigarette is......................................
0.0136125
0.0013181
0.0153785
2002
0.0136125
0.0017660
The rate per cigarette is......................................
0.0194953
2003
The rate per cigarette is......................................
0.0167539
0.0027414
0.0201300
2004
The rate per cigarette is......................................
0.0167539
0.0033761
0.0208176
2005
0.0167539
0.0040637
The rate per cigarette is......................................
0.0214421
2006
The rate per cigarette is......................................
0.0167539
0.0046882
0.0251069
2007
The rate per cigarette is......................................
0.0188482
0.0062587
0.0258601
2008
0.0188482
0.0070119
The rate per cigarette is......................................
0.0266359
2009
The rate per cigarette is......................................
0.0188482
0.0077877
0.0274350
2010
The rate per cigarette is......................................
0.0188482
0.0085868
0.0282581
2011
0.0188482
0.0094099
The rate per cigarette is......................................
0.0291058
2012
0.0188482
0.0102576
The rate per cigarette is......................................
2. Escrow payment required.
Multiply the number of cigarettes sold on line 1 by the appropriate rate in
column C. (Refer generally to Exhibit C of the Tobacco Master Settlement Agreement for calculation of the cumulative
adjustment for inflation applicable to each year’s escrow payment) ............................................................................. $
B. Financial Institution Certification
(To be completed by Authorized Agent of Financial Institution where the escrow account was established)
Representative Name
Phone Number
Name of Institution
Fax Number
Mailing Address
City
State
Zip Code
Escrow Account Number
State Account Number
Email Address
Amount deposited into the qualified escrow account for the sales year identified in Part II .......................................... $
Balance as of
in qualified escrow account for the benefit of the State of Alaska ............................... $
Date
C. Escrow Deposit/Withdrawal History for Alaska
Date
Deposit
Withdrawal
Balance
Note: Initial certification should include a complete history of activity in the escrow account. Annual certifications thereafter should be for the
applicable sales year.
510
0405-510 Rev 04/10/13 - page 2
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