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2007

State of Connecticut

Certification for Calendar Year

Form TPM-1

Certification of Compliance and Affidavit by Nonparticipating Manufacturer

Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2007

(Rev. 03/08)

Complete this form in blue or black ink only. An authorized agent of the nonparticipating manufacturer must complete and sign

Part I before a notary public. The nonparticipating manufacturer is also responsible for having an authorized agent of the financial

institution complete and sign Part II before a notary public and for filing Form TPM-1, Certification of Compliance and Affidavit by

Nonparticipating Manufacturer, with the Office of the Attorney General on or before April 30, 2008. Attach Form TPM-3, Brand Families

Unit Sales Schedule, to this form. Read the additional instructions on the back of this form.

–

Part I

To be completed by a nonparticipating manufacturer and signed before a notary public.

1. Name of Nonparticipating Manufacturer

2. Telephone Number

(

)

3. Address

Number and Street

P O Box

4. Facsimile (FAX) Number

(

)

5a. City, Town, or Post Office

5b. State or Province

5c. Country

6. Email Address

7. Name of financial institution holding the qualified escrow fund for Connecticut

8. Account and sub-account numbers of the qualified escrow fund for Connecticut

9. Number of nonparticipating manufacturer’s cigarettes sold to consumers within Connecticut whether directly or

through a distributor, dealer, or similar intermediary or intermediaries during calendar year 2007

10. Amount required to be placed into the qualified escrow fund for Connecticut sales: Multiply Line 9 by $0.0251069.

11. Amount placed into the qualified escrow fund for Connecticut and attributable to Connecticut sales reported on Line 9

12. Account balance of the qualified escrow fund for Connecticut, including amount reported on Line 11

Declaration: I declare under the penalty of false statement that I have examined Part I of this form and, to the best of my knowledge

and belief, it is true, complete, and correct. The penalty for false statement is imprisonment not to exceed one year or a fine not to

exceed $2,000, or both. I authorize the financial institution named above to verify the balance in the bank account identified above, and

any deposits thereto and withdrawals therefrom, for the State of Connecticut, Office of the Attorney General, upon request by that office.

______________________________________________________

____________________________________________

_________________________

Signature of Authorized Agent of Nonparticipating Manufacturer

Printed or Typed Name of Authorized Agent

Title of Authorized Agent

Subscribed and Sworn to Before Me This _______________________ day of _____________________ , 20 ______

My Commission Expires:

____________________________________________

____________________________

Signature (Notary Public)

–

Part II

To be completed by financial institution holding qualified escrow fund and signed before a notary public.

Name of financial institution holding the qualified escrow fund

Telephone Number

(

)

Address

Number and Street

P O Box

Facsimile (FAX) Number

(

)

City, Town, or Post Office

State

ZIP Code

Email Address

Declaration: I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into

the bank account identified above, and that I have examined Part II of this form and, to the best of my knowledge and belief, it is true,

complete, and correct. The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed $2,000, or both.

In accordance with the authorization given by the nonparticipating manufacturer mentioned above, I agree to verify the balance in the

account identified above, and any deposits thereto and withdrawals therefrom, for the State of Connecticut, Office of the Attorney

General, upon request by that office.

______________________________________________________

____________________________________________

_________________________

Signature of Authorized Agent of Financial Institution

Printed or Typed Name of Authorized Agent

Title of Authorized Agent

Subscribed and Sworn to Before Me This _______________________ day of _____________________ , 20 ______

My Commission Expires:

____________________________________________

____________________________

Signature (Notary Public)

Form Tpm-1 - Certification Of Compliance And Affidavit By Nonparticipating Manufacturer - 2007

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