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State of Connecticut

Certiﬁ cation for calendar year

2012

Form TPM-1

Certiﬁ cation of Compliance and Afﬁ davit by Nonparticipating Manufacturer

Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2012

(Rev. 04/13)

Complete Form TPM-1 in blue or black ink only. Read the additional

the ﬁ nancial institution complete and sign Part II before a notary

instructions on the back of this form.

public and for ﬁ ling Form TPM-1 with the Ofﬁ ce of the Attorney

General on or before April 30, 2013.

An authorized agent of the nonparticipating manufacturer must

complete and sign Part I before a notary public. The nonparticipating

Attach Form TPM-3, Brand Families Unit Sales Schedule, to this

manufacturer is also responsible for having an authorized agent of

form.

–

Part I

To be completed by a nonparticipating manufacturer and signed before a notary public.

Name of nonparticipating manufacturer

Telephone number

(

)

Address

Number and street

PO Box

Facsimile (Fax) number

(

)

City, town, or post ofﬁ ce

State or province

Country

Email address

1. Financial institution holding the qualiﬁ ed escrow fund for Connecticut

2. Account and sub-account numbers of the escrow fund for Connecticut

3a. Enter the quantity (sticks) of cigarettes sold to consumers within Connecticut.

Enter amount from Schedule A, Line 1.

3a.

3b. Enter the quantity (sticks) of roll-your-own cigarette tobacco sold to consumers

within Connecticut. Enter amount from Schedule B, Line 1

3b.

3. Add Line 3a and Line 3b.

4. Amount required to be placed into the qualiﬁ ed escrow fund for Connecticut sales: Multiply Line 3 by $.0291058.

5. Amount placed into the qualiﬁ ed escrow fund for Connecticut (attributable to Connecticut sales reported on Line 3)

6. Account balance of the qualiﬁ ed escrow fund for Connecticut, including amount reported on Line 5.

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, a ﬁ ne not to exceed $2,000, or both. I authorize the ﬁ nancial

institution named above to verify the balance in the bank account identiﬁ ed above, and any deposits thereto and withdrawals therefrom, for the State of

Connecticut, Ofﬁ ce of the Attorney General, upon request by that ofﬁ ce.

_______________________________________________________

_____________________________________________

___________________________

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

_______________________________________

________________________________

__________

My commission expires:

______________________________________________

____________________________

Signature of notary public

–

Part II

To be completed by ﬁ nancial institution holding qualiﬁ ed escrow fund and signed before a notary public.

Name of ﬁ nancial institution holding the qualiﬁ ed escrow fund

Telephone number

(

)

Address

Number and street

PO Box

Fax number

(

)

City, town, or post ofﬁ ce

State or province

ZIP code

Email address

Declaration: I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into the bank account

identiﬁ ed 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, a ﬁ ne 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 identiﬁ ed above, and any deposits thereto and withdrawals therefrom, for the

State of Connecticut, Ofﬁ ce of the Attorney General, upon request by that ofﬁ ce.