Schedule E - Part I - Roll-Your-Own Tobacco Purchased, Acquired, Or Shipped Into Connecticut During The Month
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6Department of Revenue Services
SCHEDULE E - Part I
State of Connecticut
Roll-your-own Tobacco
Excise/Public Services Taxes Subdivision
Purchased, Acquired, or Shipped Into Connecticut During the Month
(Rev. 01/05)
Read instructions for Part I and II carefully.
This Schedule must be completed each month unless you check the appropriate box on Form OP-300, Tobacco Products Tax Return. As used in these instructions, participating manufacturer means
a tobacco product manufacturer that is a signatory to the Master Settlement Agreement (MSA). For an up-to-date list of participating manufacturers, visit the internet web site of the National Association of
Attorneys General at and click on “Tobacco Settlement Documents” and then “Participating Manufacturers and Brand Names under the MSA.”
Distributor’s Name _______________________________________________________________ Connecticut Tax Registration Number __________________________________
Distributor’s Address ____________________________________________________________ Month of _______________________________________ Year __________________
Part I - Roll-Your-Own Tobacco Purchased Directly from Participating Manufacturer
Instructions
Report in this Part the total weight of roll-your-own tobacco you purchased (or had shipped to you in Connecticut) during the month and you purchased directly from a participating manufacturer; the
name, address and Federal Employer Identification Number (FEIN) of the participating manufacturer; and the brands of roll-your-own tobacco. Complete all columns. Attach additional sheets if
necessary.
Participating
Participating Manufacturer’s Name and Address
Brand(s) of Roll-your-own Tobacco
Total Weight
Manufacturer’s FEIN
Net Weight of Each
Quantity
Line 1. Subtotal (For this page) ....................................................................................................................................................................................... 1
Line 2. Total from attached Schedule E, Part I, additional sheet(s) .... (Number of Additional Sheet(s) _________ ) ................................................ 2
Line 3. Total Part I (Add Line 1 and Line 2.) ................................................................................................................................................................... 3
Line 4. Total from Part II, Subpart A, Line 3 ..................................................................................................................................................................... 4
Line 5. Total from Part II, Subpart B, Line 3 ..................................................................................................................................................................... 5
Line 6. Total weight of roll-your-own tobacco (Add Lines 3, 4, and 5.) ........................................................................................................................... 6
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