Schedule H - Part I - Cigarette Packages Stamped During The Month

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Department of Revenue Services

Schedule H - Part I

PO Box 5031

Hartford CT 06102-5031

Cigarette Packages Stamped During the Month

(Rev. 02/07)

Read instructions for Parts I and II carefully.

Schedule H must be completed for each month, even if no cigarette packages were stamped during the month, and attached to Form CT-15, Monthly Tax Stamp and Cigarette Report—Resident

Distributor, or Form CT-15A, Monthly Tax Stamp and Cigarette Report—Nonresident Distributor, as the case may be. Because you may only lawfully stamp cigarettes in brand families listed in the

Connecticut Tobacco Directory check the most recent update of the Connecticut Tobacco Directory and any email notifications from Department of Revenue Services (DRS) before stamping any

cigarettes and for an identification of a cigarette manufacturer as either a participating manufacturer or a nonparticipating manufacturer. See Informational Publication 2006(28), Licensed

Stamping Distributor’s Guide to Connecticut Cigarette Tax Laws and Other Cigarette-Related Laws, for more information.

Distributor’s Name _______________________________________________________________ CT Tax Registration Number ___________________________________________

Distributor’s Address ____________________________________________________________ Month of ______________________________________ Year __________________

Part I - Cigarettes Purchased Directly From a Participating Manufacturer

Report in Part 1 the number of Connecticut cigarette tax stamps you affixed during the month to packages of cigarettes you purchased directly from a participating manufacturer; the name, address,

and Federal Employer Identification Number (FEIN) of the participating manufacturer; and the brand families of the cigarettes. Complete all columns. Attach additional sheets if necessary.

Cigarette Brand Family

Number of Connecticut Tax Stamps Affixed

Participating Manufacturer’s FEIN

Participating Manufacturer’s Name and Address

20’s

25’s

Line 1. Subtotal for this page. ............................................................................................................................................ 1

Line 2. Total from attached Schedule H, Part I, Additional Sheet(s) .......... Number of additional sheet(s) ________

Line 3. Total Part I: Add the number of stamps for each denomination. Add Line 1 and Line 2. ...................................... 3

Line 4. Total from Part II, Subpart A, Line 3 ........................................................................................................................ 4

Line 5. Total from Part II, Subpart B, Line 3 ........................................................................................................................ 5

Line 6. Total number of cigarette packages stamped: Add Lines 3, 4, and 5. .................................................................. 6

Line 7. Number of cigarettes: Multiply Line 6 by 20 or 25, as applicable. ......................................................................... 7

Line 8. Total number of cigarettes stamped: Add both columns on Line 7. ............................................................................................................... 8

This amount must equal the amount shown on Form CT-15 (Resident Distributor), Line 18, or Form CT-15A (Nonresident Distributor), Line 11.