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State of Connecticut

2011

Certification for calendar year

Form TPM-1

Certiﬁ cation of Compliance and Afﬁ davit by Nonparticipating Manufacturer

Cigarettes Sold to Consumers Within Connecticut During Calendar Year 2011

(Rev. 03/12)

Complete this form in blue or black ink only. An authorized agent of the nonparticipating manufacturer must complete and sign

Part I before a notary public. The nonparticipating manufacturer is also responsible for having an authorized agent of the ﬁ nancial institution

complete and sign Part II before a notary public and for ﬁ ling Form TPM-1, Certiﬁ cation of Compliance and Afﬁ davit by Nonparticipating

Manufacturer, with the Ofﬁ ce of the Attorney General on or before April 30, 2012. Attach Form TPM-3, Brand Families Unit Sales Schedule,

to this form. Read the additional instructions on the back of this form.

–

Part I

To be completed by a nonparticipating manufacturer and signed before a notary public.

1. Name of nonparticipating manufacturer

2. Telephone number

(

)

3. Address

Number and street

PO Box

4. Facsimile (Fax) number

(

)

5a. City, town, or post ofﬁ ce

5b. State or province

5c. Country

6. Email address

7. Name of ﬁ nancial institution holding the qualiﬁ ed escrow fund for Connecticut

8. Account and sub-account numbers of the qualiﬁ ed escrow fund for Connecticut

9. Number of nonparticipating manufacturer’s cigarettes sold to consumers within Connecticut whether directly or

through a distributor, dealer, or similar intermediary or intermediaries during calendar year 2011

10. Amount required to be placed into the qualiﬁ ed escrow fund for Connecticut sales: Multiply Line 9 by $.0282581.

11. Amount placed into the qualiﬁ ed escrow fund for Connecticut and attributable to Connecticut sales reported on Line 9

12. Account balance of the qualiﬁ ed escrow fund for Connecticut, including amount reported on Line 11

Declaration: I declare under the penalty of false statement that I have examined Part I of this form and, to the best of my knowledge and

belief, it is true, complete, and correct. The penalty for false statement is imprisonment not to exceed one year, a ﬁ ne not to exceed $2,000,

or both. I authorize the ﬁ nancial institution named above to verify the balance in the bank account identiﬁ ed above, and any deposits thereto

and withdrawals therefrom, for the State of Connecticut, Ofﬁ ce of the Attorney General, upon request by that ofﬁ ce.

_______________________________________________________

_____________________________________________

___________________________

Signature of authorized agent of nonparticipating manufacturer

Printed or typed name of authorized agent

Title of authorized agent

Subscribed and sworn to before me this

day of

, 20

_______________________________________

________________________________

__________

My commission expires:

______________________________________________

____________________________

Signature of notary public

–

Part II

To be completed by ﬁ nancial institution holding qualiﬁ ed escrow fund and signed before a notary public.

Name of ﬁ nancial institution holding the qualiﬁ ed escrow fund

Telephone number

(

)

Address

Number and street

PO Box

Fax number

(

)

City, town, or post ofﬁ ce

State

ZIP code

Email address

Declaration: I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into the

bank account identiﬁ ed above and that I have examined Part II of this form and, to the best of my knowledge and belief, it is true, complete,

and correct. The penalty for false statement is imprisonment not to exceed one year, a ﬁ ne not to exceed $2,000, or both. In accordance

with the authorization given by the nonparticipating manufacturer mentioned above, I agree to verify the balance in the account identiﬁ ed

above, and any deposits thereto and withdrawals therefrom, for the State of Connecticut, Ofﬁ ce of the Attorney General, upon request

by that ofﬁ ce.