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QUARTERLY ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Non-Participating Manufacturer) (Columbia Gorge Community College)

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Quarterly Escrow Compliance Certificate and Affidavit
1244047-v1 (Revised: 04-06-2020)
Page 1 of 3
QUARTERLY ESCROW COMPLIANCE CERTIFICATE
AND AFFIDAVIT
(Non-Participating Manufacturer)
Part 1: Sales Year
SALES YEAR: SALES QUARTER:
NOTE: YOU MUST ALSO FILE AN ANNUAL ESCROW COMPLIANCE CERTIFICATE ON
OR BEFORE APRIL 25 EACH YEAR. THE ANNUAL FORM IS IN ADDITION TO THIS
QUARTERLY FORM. You can obtain the annual form at doj.state.or.us
Part 2: Manufacturer Identification
Name:
Mailing Address:
City:
State:
Zip:
Country:
Physical Address:
City:
State:
Zip:
Country:
Phone:
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.
Brand Name (Omit styles such as Regular,
Menthol, Light, etc.
Cigarettes
(C) or RYO
(RYO)
Number of Units Sold
During the Reporting
Period
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Quarterly Escrow Compliance Certificate and Affidavit
1244047-v1 (Revised: 04-06-2020)
Page 2 of 3
Part 4: Calculation of Deposit Amount
For the sales reporting period:
2003 – 2006 – The rate per cigarette is ……………………..
0.0167539
2007 and thereafter – The rate per cigarette is …………. 0.0188482
A. The appropriate rate for the reporting period is: ..........
B. Deposit Subtotal (Multiply total number of all units
in Part 3 by the appropriate cigarette rate in Part 4 above)
.............
C. The Inflation Adjustment (Refer to www.doj.state.or.us
Multiply Line B – Deposit Subtotal by the applicable inflation
adjustment percentage)
...............................................................
D. Total Escrow Deposit (Add Line B – Deposit Subtotal and
Line C – Inflation Adjustment)
.......................................................
Part 5: Financial Institution
Name of Institution:
Authorized Contact Name and Title:
Phone:
Fax:
Email:
Address:
Escrow Account No:
Sub-Account No: (if applicable)
Total Funds Held in a Separate Account for Oregon: $
Date of Escrow Agreement:
Date of Last Amendment to Escrow Agreement:
Attached is a copy of the financial institution’s receipt or other proof of deposit of the
proper escrow payment.
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
Compliance Certificate, including but not limited to the attachments herewith, are true,
complete and accurate. This Escrow Compliance Certificate 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 Compliance
Certificate Affidavit 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
SEAL:
Quarterly Escrow Compliance Certificate and Affidavit
1244047-v1 (Revised: 04-06-2020)
Page 3 of 3
ALTERNATIVE EXECUTION
BY AUTHORIZED DESIGNEE
Declaration made within the United States
The undersigned certifies that as of the date of this Certification, the above-named Applicant is
a Participating Manufacturer under the Tobacco Master Settlement Agreement as defined in ORS
180.405 (6).
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this Certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct, accurate and complete in every particular, and that I am
a person authorized to bind the Tobacco Product Manufacturer making this Certification either
under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is
organized. Any violation of the requirements of ORS 323.800 to 323.806 or ORS 180.400
to 180.455 is a basis for removal of the applicant’s Brands from Oregon’s Directory of
compliant Tobacco Product Manufacturers.
I hereby declare that the above statement is true to the best of my knowledge and belief, and
that I understand it is made for use as evidence in court and is subject to penalty for perjury
Signature of Authorized Person:
Date:
Printed Name of Authorized Person:
Title:
Declaration made outside the boundaries of the United States
The undersigned certifies that as of the date of this Certification, the above-named Applicant is
a Participating Manufacturer under the Tobacco Master Settlement Agreement as defined in ORS
180.405 (6).
Under penalty of perjury, I certify and declare that all of the statements and information
contained in this Certification, including but not limited to any accompanying statements or
attachments herewith, are true, correct, accurate and complete in every particular, and that I am
a person authorized to bind the Tobacco Product Manufacturer making this Certification either
under the laws of the State of Oregon or of the jurisdiction where the manufacturer resides or is
organized. Any violation of the requirements of ORS 323.800 to 323.806 or ORS
180.400 to 180.455 is a basis for removal of the applicant’s Brands from Oregon’s
Directory of compliant Tobacco Product Manufacturers.
I declare under penalty of perjury under the laws of Oregon that the foregoing is
true and correct, and that I am physically outside the geographic boundaries of the
United States, Puerto Rico, the United States Virgin Islands, and any territory or
insular possession subject to the jurisdiction of the United States.
Executed on the (day) of (month), (year) at (city or other
location), (country).”
Signature of Authorized Person:
Date:
Printed Name of Authorized Person:
Title:
(day)
(month)
(year)
(city or other location)
(country)
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QUARTERLY ESCROW COMPLIANCE CERTIFICATE AND AFFIDAVIT (Non-Participating Manufacturer) (Columbia Gorge Community College)

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Completed 15 August 2020

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