Form 3762 2018 Quarterly Certification of Compliance by Nonparticipating Manufacturer (Npm) - Michigan

Form 3762 is a Michigan Department of Treasury form also known as the "Quarterly Certification Of Compliance By Nonparticipating Manufacturer (npm)". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a fillable PDF version of the Form 3762 down below or find it on Michigan Department of Treasury Forms website.

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Michigan Department of Treasury
Reset Form
3762 (Rev. 04-18)
2018 Quarterly Certification of Compliance by Nonparticipating Manufacturer (NPM)
Issued under authority of Public Act 327 of 1993 and Public Act 244 of 1999. Filing is mandatory.
SECTION 1: TOBACCO PRODUCT MANUFACTURER’S IDENTIFICATION
1. NPM Name
2. Account Number (FEIN, TR or ME Number)
3. Address (Street, City, State, ZIP Code)
4. Contact Person
5. Telephone Number
6. Fax Number
7. E-mail Address
SECTION 2: APPLICABLE CALENDAR QUARTER
Quarter
2018 Time Periods
Deposit Deadline
Certification Deadline (Form 3762)
1
January 1 - March 31, 2018
April 30, 2018
May 15, 2018
2
April 1 - June 30, 2018
July 31, 2018
August 15, 2018
3
July 1 - September 30, 2018
October 31, 2018
November 15, 2018
4
October 1 - December 31, 2018
January 31, 2019
February 15, 2019
SECTION 3: CERTIFICATION
I hereby certify that the NPM named in Section 1 is not a participant in the Master Settlement Agreement and that, in accordance with 1999 PA 244, MCL
445.2051 to 445.2052, it has performed its obligation to establish a qualified escrow account and that it has, for the calendar quarter marked above,
deposited funds into that account as described in the Quarterly Statement of Deposit accompanying this Certification.
Name of Officer or Authorized Agent
Title
Signature of Officer or Authorized Agent
Date
SECTION 4: SIGNATURE
I declare under penalty of perjury that the information contained in this Certification of Compliance and attachments is true and complete to the best of
my knowledge.
Name of Officer or Authorized Agent
Title
Signature of Officer or Authorized Agent
Date
Mail the original to:
Michigan Department of Treasury,
Tobacco Tax Unit
P.O. Box 30474
Lansing, MI 48909
Also mail a copy to:
Office of Attorney General
Revenue & Collections Division
525 W. Ottawa
P.O. Box 30754
Lansing, MI 48909
For questions, call 517-636-4630.
If your name does not appear on the Non-Participating Manufacturer (NPM) Tobacco Products That May Be Sold in Michigan
list published at www.michigan.gov/tobaccotaxes identifying authorized NPM’s and their brands, you are prohibited from selling, or
having your brands sold for consumption in Michigan.
Michigan Department of Treasury
Reset Form
3762 (Rev. 04-18)
2018 Quarterly Certification of Compliance by Nonparticipating Manufacturer (NPM)
Issued under authority of Public Act 327 of 1993 and Public Act 244 of 1999. Filing is mandatory.
SECTION 1: TOBACCO PRODUCT MANUFACTURER’S IDENTIFICATION
1. NPM Name
2. Account Number (FEIN, TR or ME Number)
3. Address (Street, City, State, ZIP Code)
4. Contact Person
5. Telephone Number
6. Fax Number
7. E-mail Address
SECTION 2: APPLICABLE CALENDAR QUARTER
Quarter
2018 Time Periods
Deposit Deadline
Certification Deadline (Form 3762)
1
January 1 - March 31, 2018
April 30, 2018
May 15, 2018
2
April 1 - June 30, 2018
July 31, 2018
August 15, 2018
3
July 1 - September 30, 2018
October 31, 2018
November 15, 2018
4
October 1 - December 31, 2018
January 31, 2019
February 15, 2019
SECTION 3: CERTIFICATION
I hereby certify that the NPM named in Section 1 is not a participant in the Master Settlement Agreement and that, in accordance with 1999 PA 244, MCL
445.2051 to 445.2052, it has performed its obligation to establish a qualified escrow account and that it has, for the calendar quarter marked above,
deposited funds into that account as described in the Quarterly Statement of Deposit accompanying this Certification.
Name of Officer or Authorized Agent
Title
Signature of Officer or Authorized Agent
Date
SECTION 4: SIGNATURE
I declare under penalty of perjury that the information contained in this Certification of Compliance and attachments is true and complete to the best of
my knowledge.
Name of Officer or Authorized Agent
Title
Signature of Officer or Authorized Agent
Date
Mail the original to:
Michigan Department of Treasury,
Tobacco Tax Unit
P.O. Box 30474
Lansing, MI 48909
Also mail a copy to:
Office of Attorney General
Revenue & Collections Division
525 W. Ottawa
P.O. Box 30754
Lansing, MI 48909
For questions, call 517-636-4630.
If your name does not appear on the Non-Participating Manufacturer (NPM) Tobacco Products That May Be Sold in Michigan
list published at www.michigan.gov/tobaccotaxes identifying authorized NPM’s and their brands, you are prohibited from selling, or
having your brands sold for consumption in Michigan.

Download Form 3762 2018 Quarterly Certification of Compliance by Nonparticipating Manufacturer (Npm) - Michigan

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