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State of Connecticut

Form TPM-1

2004

Calendar Year

Certification of Compliance and Affidavit by Nonparticipating Manufacturer

Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2004

(Rev. 03/05)

Important:

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 with the Office of the Attorney General on or before April 30, 2005. Attach Form

TPM-3, 2004 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

(

)

3. Address (number and street) or PO Box

4. FAX

(

)

5a. City, Town, or Post Office

5b. State or Province

5c. Country

6. E-mail Address

7. Name of financial institution holding the qualified escrow fund

8. Account number of the qualified escrow fund

9. Has money been placed into the qualified escrow fund for other settling states?

10. Account balance (including

amount reported in Box 13)

Yes

11. 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 2004.

12. Amount required to be placed into the qualified escrow fund for Connecticut sales

(Multiply Box 11 by $.0201300)

13. Amount placed into the qualified escrow fund and attributable to Connecticut sales reported in Box 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 ________ .

___________________________________________________

___________________________________________

Signature (Notary Public)

My Commission expires:

Part II –

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

14. Name of financial institution holding the qualified escrow fund

15. Telephone

(

)

16. Address (number and street) or PO Box

17. FAX

(

)

18a. City, Town, or Post Office

18b. State

18c. ZIP Code

19. E-mail 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 ________ .

___________________________________________________

___________________________________________

Signature (Notary Public)

My Commission expires:

Form Tpm-1 - Certification Of Compliance And Affidavit By Nonparticipating Manufacturer - Connecticut Finance Department - 2004

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