Form TPM-3 State of Connecticut Calendar year 2010 Brand Families Unit Sales Schedule Sales Made During Calendar Year 2010 This form must be submitted with the 2010 Form TPM-1, Certification of Compliance and Affidavit by Nonparticipating Manufacturer. (Rev. 03/11)  Company is a (Check one.) Complete this form in blue or black ink only. Manufacturer  Importer Check if this is an amended form.  Department of Revenue Services (DRS) Cigarette Manufacturer License Number Company name City, town, or post office State or province Telephone number Facsimile (FAX) number Email address ( ( Company address Number and street ) PO Box Country ) Part I - Instructions Column A: List all brand families sold during calendar year 2010. Indicate by asterisk (*) any brand family no longer sold in Connecticut as of the date this form is signed. Column B:    Product type codes Enter C for any brand family of cigarettes. Enter RYO for any brand family of roll-your-own tobacco. Each 0.09 ounce of roll-your-own tobacco constitutes one stick. Enter LC for any brand family of little cigars that are properly treated as cigarettes for the purposes of the federal excise tax on cigarettes (26 U.S.C. §5701(b)). Column C: List the total sticks sold in Connecticut during calendar year 2010. Column D: If the reporting company is not the manufacturer (the fabricator), provide the name, address, and Federal Employee Identification Number (FEIN) of the manufacturer. Part I - Total sales made to consumers within Connecticut, whether directly or through a distributor, dealer, or similar intermediary or intermediaries, during calendar year 2010 Column A Brand Family Name(s) Column B Product Type Codes Column D Manufacturer (Fabricator) Name, Address, and FEIN Column C Total Sticks                                                         Attach additional sheet(s) as necessary to provide a complete response. Complete Part II and Declaration on Page 2. American LegalNet, Inc. www.FormsWorkFlow.com State of Connecticut Form TPM-3 Brand Families Unit Sales Schedule Sales Made to Date During Calendar Year 2011 Company name Department of Revenue Services (DRS) Cigarette Manufacturer License Number Part II - Instructions Column A: Column B:    Column C: Column D: List all brand families that have been sold to date during calendar year 2011 to consumers within Connecticut. Product type codes  Enter C for any brand family of cigarettes.  Enter RYO for any brand family of roll-your-own tobacco. Each 0.09 ounce of roll-your-own tobacco constitutes one stick.  Enter LC for any brand family of little cigars that are properly treated as cigarettes for purposes of the federal excise tax on cigarettes (26 U.S.C. §5701(b)). List the total sticks sold to date during calendar year 2011 to consumers within Connecticut. If the reporting company is not the manufacturer (the fabricator), provide the name, address, and Federal Employee Identification Number (FEIN) of the manufacturer. Part II - Sales made to date during calendar year 2011 to consumers within Connecticut, whether directly or through a distributor, dealer, or similar intermediary or intermediaries Column A Brand Family Name(s) Column B Product Type Codes Column D Manufacturer (Fabricator) Name, Address, and FEIN Column C Total Sticks                                                         Attach additional sheet(s) as necessary to provide a complete response. Declaration: Under penalty of perjury under the laws of Connecticut, I declare that I am authorized to certify on behalf of the reporting company named above and all of the information contained in this form is complete and accurate. Signature of company officer Date Print name of company officer Email address Print title of company officer Form TPM-3, Part II (Rev. 03/11) Telephone number Fax number Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com