Schedule H - Part I - Cigarette Packages Stamped During The Month Page 3

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Schedule H - Part II, Subpart A

Cigarette Packages Stamped During the Month

Distributor’s Name _______________________________________________________________ CT Tax Registration Number ___________________________________________

Distributor’s Address ____________________________________________________________ Month of ____________________________________________________________

Part II—Cigarettes Not Purchased Directly From a Participating Manufacturer

Subpart A—Cigarettes Manufactured by a Participating Manufacturer but Not Purchased Directly From the Participating Manufacturer

Report in Subpart A the number of Connecticut cigarette tax stamps you affixed during the month to packages of cigarettes that were manufactured by a participating manufacturer, but that you did not

purchase directly from the participating manufacturer; the name, address, and FEIN of the person from which you purchased the cigarettes (Supplier); and the brand families of those cigarettes. Also

report in Subpart A the name, address, and FEIN of the participating manufacturer. 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 DRS before stamping any cigarettes. See Informational Publication 2006(28), Licensed Stamping

Distributor’s Guide to Connecticut Cigarette Tax Laws and Other Cigarette-Related Laws, for more information. Complete all columns. Attach additional sheets if necessary.

Number of Connecticut Tax Stamps Affixed

Cigarette Brand Family

Participating Manufacturer’s

Supplier’s Name, Address, and FEIN

Name, Address, and FEIN

20’s

25’s

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

Line 2. Total from attached Schedule H - Part II, Subpart A, Additional Sheet(s). Number of additional sheet(s) _____

Line 3. Total number of cigarette packages stamped: Add Line 1 and Line 2. Enter total on Part I, Line 4. ....................

Schedule H - Part II, Subpart A (Rev. 02/07)

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