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Schedule E - Part I - Roll-Your-Own Tobacco Purchased, Acquired, Or Shipped Into Connecticut During The Month Page 5

Schedule E - Part II, Subpart B

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 ____________________________________________________________

Subpart B—Roll-Your-Own Tobacco Products Not Manufactured by a 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 not manufactured by a 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 nonparticipating manufacturer or first purchaser. Complete all columns. Attach additional sheets if necessary.

•

A nonparticipating manufacturer means a tobacco product manufacturer that is not a participating manufacturer and manufacturers roll-your-own tobacco it intends to be sold in the

United States, including roll-your-own tobacco it intends to be sold through an importer.

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A first purchaser means a person or other entity that is not a participating manufacturer and is responsible for the roll-your-own tobacco being designated for sale in the United States

where the roll-your-own tobacco was not originally intended by its manufacturer to be sold in the United States.

Nonparticipating Manufacturer’s or

Brand(s) of Roll-your-own

Supplier’s Name, Address, and FEIN

Quantity

Net Weight of Each

Total Weight

First Purchaser’s Name, Address and FEIN

Tobacco

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

Line 2. Total from attached Schedule E - Part II, Subpart B, 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 5 ..........................................................................

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

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