Form Tpm-1 - Certification Of Compliance And Affidavit By Nonparticipating Manufacturer - 2012 Page 2
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2Schedules A and B – To be completed by a nonparticipating manufacturer
Schedule A - Cigarettes (sticks) sold to consumers within Connecticut
Enter brand, purchaser’s name, and the number of cigarettes (sticks) sold to consumers within Connecticut, whether directly or through
a distributor, dealer, or similar intermediary or intermediaries, during calendar year 2012. Also report the purchaser’s “stamper” status to
the right of Column B. Attach additional sheet(s) as necessary to provide a complete response.
Column B
Column C
Column A
Stamper
Brand
Name of Purchaser of Cigarettes and Stamper Status
Number of Cigarettes (sticks)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1. Total from Column C: enter here and on Part I, Line 3a. ................................................. 1.
Schedule B -
Roll-your-own cigarette tobacco (converted to sticks) sold to consumers within Connecticut
Enter brand, purchaser’s name, and the quantity of roll-your-own cigarette tobacco (in sticks) sold to consumers within Connecticut, whether
directly or through a distributor, dealer, or similar intermediary or intermediaries, during calendar year 2012. Each nine one-hundredths of an
ounce (0.09) of roll-your-own cigarette tobacco constitutes one stick. Attach additional sheet(s) as necessary to provide a complete response.
Column B
Column C
Column A
Name of Purchaser of Roll-your-own Cigarette tobacco
Ounces Converted to Sticks
Brand
1. Total from Column C: enter here and on Part I, Line 3b. ..................................................1.
Form TPM-1 - Instructions
Who Must File
On or before April 30, 2013, the nonparticipating manufacturer
must send Form TPM-1, Form TPM-3, Brand Families Unit
Each nonparticipating manufacturer selling cigarettes to consumers
Sales Schedule, and a copy of the escrow agreement signed by the
within Connecticut, whether directly or through a distributor,
nonparticipating manufacturer and the fi nancial institution to the
dealer, or similar intermediary or intermediaries, must establish a
following address:
qualifi ed escrow fund for the benefi t of the State of Connecticut
and other settling states, place the required amount of money into
Offi ce of the Attorney General
a qualifi ed escrow fund, and fi le Form TPM-1, Certifi cation of
Finance Department
Compliance and Affi davit by Nonparticipating Manufacturer. For
PO Box 120
more information on completing this form, see Announcement
Hartford CT 06141-0120
2013(4), Annual Revision of Forms TPM-1, TPM-2, and TPM-3.
For further information contact:
When and Where to File
Offi ce of the Attorney General
State of Connecticut
On or before April 15, 2013, the nonparticipating manufacturer must
place the required amount of money into a qualifi ed escrow fund.
860-808-5270
Form TPM-1 Back (Rev. 04/13)
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