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Schedule E - Part I - Roll-Your-Own Tobacco Purchased, Acquired, Or Shipped Into Connecticut During The Month Page 3

Schedule E - Part II, Subpart A

Roll-your-own Tobacco

Purchased, Acquired, or Shipped Into Connecticut During the Month

Distributor’s Name _______________________________________________________________ CT Tax Registration Number ___________________________________________

Distributor’s Address ____________________________________________________________ Month of ____________________________________________________________

Part II—Roll-your-own Tobacco Products Not Purchased Directly From a Participating Manufacturer

Subpart A—Roll-your-own Tobacco Manufactured by a Participating Manufacturer but Not Purchased Directly From the Participating Manufacturer

Report in this Subpart the total weight of roll-your-own tobacco you purchased (or had shipped to you in Connecticut) during the month and was manufactured by a participating manufacturer, but

was not purchase directly from the participating manufacturer; the name, address, and Federal Employer Identification Number (FEIN) of the person from whom you purchased the roll-your-own

tobacco (“Supplier”); and the brands of roll-your-own tobacco. Also report in this Subpart the name, address, and FEIN of the participating manufacturer. Complete all columns. Attach additional sheets

if necessary.

Participating Manufacturer’s

Brand(s) of Roll-your-own

Supplier’s Name, Address, and FEIN

Quantity

Net Weight of Each

Total Weight

Name, Address, and FEIN

Tobacco

Line 1. Subtotal (For this page) ....................................................................................................................................................................................

Line 2. Total from attached Schedule E - Part II, Subpart A, additional sheet(s). (Number of Additional Sheet(s) ______________ ) ...................

Line 3. Total weight of roll-your-own tobacco (Add Line 1 and Line 2.) Enter total on Part I, Line 4 ..........................................................................

Schedule E - Part II, Subpart A (Rev. 01/05)

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