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

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Schedule E - Part II, Subpart B

Roll-Your-Own Tobacco

Purchased, Acquired, or Shipped Into Connecticut During the Month



Distributor’s name _________________________________________________________________ Connecticut Tax Registration Number _____________________________________



Distributor’s address ______________________________________________________________ Month of _____________________________________________________________

Subpart B—Roll-Your-Own Tobacco Products Not Manufactured by a Participating Manufacturer

Report in Subpart B the total weight of roll-your-own tobacco you purchased (or had shipped to you in Connecticut) during the month and that was not manufactured by a participating manufacturer; the

name, address, and FEIN of the person from whom you purchased the roll-your-own tobacco (Supplier); and the brand families of the roll-your-own tobacco. Also report in Subpart B the name, address, and

FEIN of the nonparticipating manufacturer or first purchaser. Complete all columns. Attach additional sheets if necessary.

 A nonparticipating manufacturer is a person identified as a nonparticipating manufacturer in the Connecticut Tobacco Directory.

 A first purchaser is a person or other entity that is not a participating manufacturer and that 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

Roll-your-own tobacco

Supplier’s name, address, and FEIN

Net weight of each

Total weight

Quantity

first purchaser’s name, address, and FEIN

brand family



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. 10/08 )

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