Schedule E Template - Purchased, Acquired Or Shipped Into Connecticut During The Month

STATE OF CONNECTICUT

SCHEDULE E

DEPARTMENT OF REVENUE SERVICES

Excise/Public Service Subdivision

Roll-your-own Tobacco Products

(Rev. 12/00)

Purchased, Acquired Or Shipped Into Connecticut During The Month

Read instructions for Part I and II carefully.

This Schedule must be completed each month (even if no roll-your-own tobacco was purchased during the month) and attached to Form OP-300, Tobacco Products Tax Return

Distributor’s Name _______________________________________________________________ Connecticut Tax Registration Number __________________________________

Distributor’s Address ____________________________________________________________ Month of _______________________________________ Year __________________

Part I - Roll-Your-Own Tobacco Purchased Directly from Manufacturers

Instructions

Include in Part I the quantity of roll-your-own packages you purchased directly from manufacturers during the month. (Roll-your-own tobacco that was not purchased directly from the manufacturer

should be reported in Part II.) List below the manufacturer’s name, address, and Federal Employer Identification Number (FEIN), and the quantity of roll-your-own packages that you purchased.

Complete all columns and attach additional sheets if necessary.

Manufacturer’s

Manufacturer’s Name and Address

Quantity

Net Weight of Each

Total Weight

FEIN

(1)

(2)

(3)

(4)

(5)

1

Line 1. Total Part I (this page) .......................................................................................................................................................................................

2

Line 2. Total from Part II, Line 1 (from back) .................................................................................................................................................................

3

Line 3. Total roll-your-own tobacco (add Line 1 and Line 2) ........................................................................................................................................