Free Form CG-30.2 - New York

New York State Department of Taxation and Finance

Information Regarding Escrow Deposit
Attachment to Form CG-30

CG-30.2

This form may only be used to report funds escrowed for sales made during calendar year 2008. To report escrow funds for any other year, contact the Tax Department for the correct form. See Form CG-30-I, Instructions for Forms CG-30, CG-30.1, and CG-30.2. Note: Form CG-30.2 must be filed only with the Commissioner of Taxation and Finance and the Attorney General of New York State (NYS). This form is not required to be submitted to the cigarette stamping agents or distributors of roll-your-own (RYO) tobacco. A copy of the escrow agreement with the financial institution must be provided to the Attorney General with this form.
Legal name of non-participating manufacturer Date Federal employer identification number (EIN)

In accordance with the provisions of Public Health Law (PHL) section 1399-pp, and as certified on Form CG-30, Certification of Tobacco Master Settlement Agreement Status, the above tobacco product manufacturer is a non-participating manufacturer in the Tobacco Master Settlement Agreement and has established all required escrow deposits for calendar year 2008, as described below. 1 List by complete brand name the number of individual cigarettes (sticks) and RYO tobacco manufactured by you and sold during calendar year 2008 in NYS Complete brand name(s)* Number of cigarettes (sticks) and RYO tobacco (.09oz.=1cigarette)

Total number of cigarettes (sticks) and RYO tobacco .............................................................

1.

* Be sure the complete brand name(s) of the cigarettes or RYO tobacco is listed, including the following (attach additional sheets, if necessary): ·filteredorunfiltered ·descriptiveinformation(suchasmentholorslim) ·size(suchasregular,king,100's,etc.) ·indicationifbrandisanRYOtobaccoproduct ·otherinformationasnecessarytoidentifytheproduct 2 Escrow rate for cigarettes and RYO tobacco sold during calendar year 2008. (This rate includes both the rate and the inflation adjustment required by PHL section 1399-pp (2).) .......................................... 2. 3 Amount deposited into the qualified escrow fund for calendar year 2008 (multiply line 1 by line 2)....................... 3. 4
Name of financial institution Address of financial institution

$ 0.0258601 $

Escrow account number

Total cumulative amount held for NYS

$