Schedule E Template - Purchased, Acquired Or Shipped Into Connecticut During The Month Page 2

Part II - Roll-Your-Own Tobacco Purchased from Other Sources

Instructions

Include in Part II the quantity of roll-your-own tobacco you purchased other than directly from the manufacturer. If you have more than one supplier with respect to any brand of roll-your-own tobacco, list all suppliers for such

brand(s). List below the name, address, and Federal Employer Identification Number of your supplier and the brand(s) of roll-your-own tobacco purchased from each such supplier. For each brand listed, enter the name, address,

and Federal Employer Identification Number of the first purchaser or manufacturer of the roll-your-own tobacco. (The first purchaser is the person or other entity responsible for the roll-your-own tobacco being designated

for sale in the United States where such roll-your-own tobacco was not originally intended for sale in the United States by the manufacturer.) If you have purchased roll-your-own tobacco which has been re-packaged

for sale in the United States (i.e., required health warnings have been affixed), such roll-your-own tobacco was not intended by their manufacturer to be sold in the United States. The manufacturer is a roll-your-

own tobacco manufacturer which manufactured roll-your-own tobacco that it intended to be sold in the United States, including roll-your-own tobacco intended to be sold in the United States through an importer.

(This roll-your-own tobacco has the required health warnings on the original packaging.) Complete all columns and attach additional sheets if necessary.

Brand(s) of

First Purchaser or Manufacturer’s

Supplier’s Name, Address and FEIN

Quantity

Net Weight Each

Total Weight

Roll-your-own

Name, Address, and FEIN

Tobacco

(1)

(2)

(3)

(4)

(5)

(6)

1

Line 1. Total for Part II (carry this total to Part I, Line 2) ...............................................................................................................................................

Schedule E - Part II - (Rev. 12/00)