Schedule H - Part I - Cigarette Packages Stamped During The Month Page 5

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Schedule H - Part II, Subpart B

Cigarette Packages Stamped During the Month

Distributor’s Name _______________________________________________________________ CT Tax Registration Number ___________________________________________

Distributor’s Address ____________________________________________________________ Month of ____________________________________________________________

Subpart B—Cigarettes Not Manufactured by a Participating Manufacturer

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

address, and Federal Employer Identification Number (FEIN) of the person from whom you purchased the cigarettes (Supplier); and the brand families of those cigarettes. Also report in Subpart B the

name, address, and FEIN of the nonparticipating manufacturer or first purchaser.

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 is responsible for the cigarettes being designated for sale in the United States where the cigarettes

were not originally intended by their manufacturer to be sold in the United States. The first purchaser repackaged those cigarettes, so that they could be sold in the United States, by affixing

the required Surgeon General’s health warning on the packaging.

Complete all columns. Attach additional sheets if necessary.

Nonparticipating Manufacturer’s or First Purchaser’s

Cigarette Brand Family

Number of Connecticut Tax Stamps Affixed

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 B, 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 5. ...................

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

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