Schedule H - Part I - Cigarette Packages Stamped During The Month Page 2

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Schedule H - Part I
Additional Sheet Number ________ of _________
Additional Sheet
Cigarette Packages Stamped During the Month
Cigarette Brand Family
Participating Manufacturer’s Name and Address
Participating Manufacturer’s FEIN
Number of Connecticut Tax Stamps Affixed
20’s
25’s
Subtotal .....................................................................................................
Enter total for Part I - Additional Sheet(s), on Schedule H - Part I, Line 2.
Schedule H - Part I, Additional Sheet (Rev. 02/07)
Page 2 of 6

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