Schedule E - Part I - Roll-Your-Own Tobacco Purchased, Acquired, Or Shipped Into Connecticut During The Month Page 4
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6Schedule E - Part II, Subpart A
Additional Sheet Number ________ of _________
Additional Sheet
Roll-your-own Tobacco Purchased, Acquired, or Shipped Into Connecticut During the Month
Brand(s) of Roll-your-own
Participating Manufacturer’s
Supplier’s Name, Address, and FEIN
Quantity
Net Weight of Each
Total Weight
Name, Address and FEIN
Tobacco
Subtotal ........................................................................................................................................
(Enter total for Part II, Subpart A - Additional Sheet(s) on Schedule E - Part II, Subpart A, Line 2.)
Schedule E - Part II, Subpart A, Additional Sheet (Rev. 01/05)
Page 4 of 6
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