Fillable ESCROW REFUND REQUEST (Non-Participating Manufacturer) (Columbia Gorge Community College)

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ESCROW REFUND REQUEST (Non-Participating Manufacturer) (Columbia Gorge Community College)

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Escrow Refund Request Page 1 of 2
DM #8359881 (Revised: 1-23-2018)
ESCROW REFUND REQUEST
(Non-Participating Manufacturer)
Part 1: Sales Year
SALES YEAR: This form must be accompanied by an amended escrow compliance
certificate.
Part 2: Manufacturer Identification
Name: FEIN No.
Mailing Address:
City: State: Zip: Country:
Physical Address:
City: State: Zip: Country:
Phone: Fax: Email:
Part 3: Units Sold
Number of units of individual cigarettes and roll-your-own
(RYO) tobacco sold in Oregon by the Manufacturer identified
above during the sales reporting period is as follows:
Total Number Units of Cigarettes
Total Ounces of Roll-Your-Own (RYO)
Total Number of Units of RYO (One unit =
.09 ounces of RYO)
TOTAL NUMBER OF ALL UNITS
Non-Participating Manufacturer Brand Information:
Please add additional sheets if necessary. Attach all invoices
and other documentation relied on in completing this request.
Brand Name Cigarettes (C)
or RYO (RYO)
Number of Units
Sold During the
Reporting Period
Oregon-licensed
distributor that sold the
product
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Escrow Refund Request Page 2 of 2
DM #8359881 (Revised: 1-23-2018)
Part 4: Explanatory Statement
Please explain why the initial certificate of compliance and escrow deposit were in error. Use
additional sheets if necessary.
Part 5: Refund Agreement
In requesting this refund, the Tobacco Product Manufacturer identified in Part 1 agrees that if
the State of Oregon discovers additional units sold, the manufacturer will deposit funds into its
Qualified Escrow Fund within ten days of a notice of deficiency.
Part 6: Signature
Under penalty of perjury, I declare that I am authorized to certify on behalf of the Tobacco
Product Manufacturer in Part 1 that all of the information contained in this Escrow Refund
Request, including but not limited to the attachments herewith, are true, complete and
accurate. This Escrow Refund Request must also be signed and dated by an
authorized notary public.
Name of Authorized Agent:
Title:
Signature of Authorized Agent:
Date:
Subscribed and sworn to before me on this date:
Signature of Notary Public: County of:
My Commission Expires:
Mail the completed original Escrow Refund Request with
attachments to:
Office of the Attorney General for the State of Oregon
Oregon Department of Justice
Civil Enforcement Division; Attn: Tobacco Enforcement
1162 Court Street, NE
Salem, OR 97301-4096
Phone: (503) 934-4400
Fax: (503) 373-7067
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ESCROW REFUND REQUEST (Non-Participating Manufacturer) (Columbia Gorge Community College)

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Completed 15 August 2020

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