2018 Non-participating Manufacturer Quarterly Certificate of Compliance Form - West Virginia

This fillable "Non-participating Manufacturer Quarterly Certificate of Compliance Form" is a document issued by the West Virginia Tax Department specifically for West Virginia residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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S
W
V
TATE OF
EST
IRGINIA
Non-Participating Manufacturer
Quarterly Certificate of Compliance
Pursuant to W.Va. Code § 16-9D-6(e)
Part 1: Tobacco Product Manufacturer Identification
Company Name:
Street Address:
City:
State/Country:
Postal Code:
Telephone:
Fax Number:
Email:
Name and Title of Person
Completing this Report:
Part 2: Liability Reporting Period
First Quarter: January 1 through March 31, 2018
May 1, 2018:
Escrow Deposit Due in West Virginia Sub-Account
May 11, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
May 11, 2018:
Account letter submitted by bank to the Attorney General
Second Quarter: April 1 through June 30, 2018
July 31, 2018:
Escrow Deposit Due in West Virginia Sub-Account
August 10, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
August 10, 2018:
Account letter submitted by bank to the Attorney General
Third Quarter: July 1 through September 30, 2018
October 31, 2018:
Escrow Deposit Due in West Virginia Sub-Account
November 12, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
November 12, 2018:
Account letter submitted by bank to the Attorney General
Fourth Quarter: October 1 through December 31, 2018
January 31, 2019:
Escrow Deposit Due in West Virginia Sub-Account
February 11, 2019:
NPM Quarterly Certificate of Compliance Received by Attorney General
February 11, 2019:
Account letter submitted by bank to the Attorney General
S
W
V
TATE OF
EST
IRGINIA
Non-Participating Manufacturer
Quarterly Certificate of Compliance
Pursuant to W.Va. Code § 16-9D-6(e)
Part 1: Tobacco Product Manufacturer Identification
Company Name:
Street Address:
City:
State/Country:
Postal Code:
Telephone:
Fax Number:
Email:
Name and Title of Person
Completing this Report:
Part 2: Liability Reporting Period
First Quarter: January 1 through March 31, 2018
May 1, 2018:
Escrow Deposit Due in West Virginia Sub-Account
May 11, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
May 11, 2018:
Account letter submitted by bank to the Attorney General
Second Quarter: April 1 through June 30, 2018
July 31, 2018:
Escrow Deposit Due in West Virginia Sub-Account
August 10, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
August 10, 2018:
Account letter submitted by bank to the Attorney General
Third Quarter: July 1 through September 30, 2018
October 31, 2018:
Escrow Deposit Due in West Virginia Sub-Account
November 12, 2018:
NPM Quarterly Certificate of Compliance Received by Attorney General
November 12, 2018:
Account letter submitted by bank to the Attorney General
Fourth Quarter: October 1 through December 31, 2018
January 31, 2019:
Escrow Deposit Due in West Virginia Sub-Account
February 11, 2019:
NPM Quarterly Certificate of Compliance Received by Attorney General
February 11, 2019:
Account letter submitted by bank to the Attorney General
Part 3: Sales by Brand Family
Brand Family
Quarterly Units Sold
Part 4: Escrow Account Information
Name of Financial Institution:
Street Address:
City:
State/Country:
Postal Code:
Contact Name/Title:
Telephone:
Fax Number:
Escrow Account Number:
West Virginia Sub-Account
Number:
The Financial Institution/Escrow Agent listed above is required to provide directly to the Attorney General’s Office the
following:
1. Proof of the amount and date of deposit to West Virginia’s segregated sub-account for the 2017 quarterly sales.
2. A current ledger of the tobacco product manufacturer’s segregated sub-account for West Virginia.
Page 2 of 4
Part 5: Quarterly Escrow Calculation for 2018 Sales
1. List on Line A the total cigarettes sold by the NPM in West Virginia
A. _______________
during the quarter. (Note: For RYO, divide the total number of ounces
(units)
sold by 0.09 and round up to the next whole unit)
2. Line B contains the applicable rate per unit sold in 2018 ($0.0188482)
B. $0.0347539
.
plus the inflation adjustment for 2018 ($0.0159057).
3. Multiply Line A and B to determine the total escrow due for the quarter.
C. _______________
ANY REQUIRED QUARTERLY ESCROW PAYMENT MUST BE DEPOSITED INTO THE
SEGREGATED WEST VIRGINIA SUB-ACCOUNT BY THE DUE DATE INDICATED IN PART 2.
Part 6: Additional Information
A. The registered agent identified in the NPM’s most recent Annual Certification has not changed since that
certification. □ Yes □ No
B. The financial institution information provided in the NPM’s most recent Annual Certification has not changed
since that certification. □ Yes □ No
C. The escrow agreement provided in the NPM’s most recent Annual Certification has not changed since that
certification. □ Yes □ No
D. If the NPM responded no to Questions A, B, or C, please provide an explanation in attachment.
Page 3 of 4
Part 7: Execution by Authorized Designee
An authorized officer of the NPM MUST sign this form and have it notarized.
Under penalty of perjury, I certify that the tobacco product manufacturer on whose behalf this certification is
made is in full compliance with West Virginia Code § 16-9B-1 et seq., that the information contained in this
certificate of compliance is true and accurate, and that I am authorized to signed this certification. I understand
that the West Virginia Office of the Attorney General may require additional information and/or documentation
to determine the veracity of assertions and representations made in this certification.
Designee:
Title:
Street Address:
City:
State/Country:
Postal Code:
Telephone:
Email:
Signature of Designee:
Date:
Subscribed and sworn to before me this ________ day of _____________________, 20_____.
County of _____________________________
Signature of Notary Public: __________________________________________
Notary Commission Expires: ________________________________________
Mail Completed Certificate of Compliance to:
West Virginia Office of the Attorney General
Tobacco Litigation Unit
Attn: Cassandra L. Means
State Capitol Complex
Building 1, Room W-435
Charleston, WV 25305
Page 4 of 4

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