Complete Form TPM-1 in blue or black ink only.Read the additional instructions on the back of this form.An authorized agent of the nonparticipating manufacturer must complete and sign Part I before a notary public. The nonparticipating manufacturer is Form TPM-1 226 2018 : I declare under penalty of false statement that the nonparticipating manufacturer named above has placed money into the bank account � � � � � � � � day of � � � � � � My commission expires: � � � � � � � � day of � � � � � � My commission expires: .226 To be completed by a nonparticipating manufacturer and signed before a notary public. Name of nonparticipating manufacturer � Telephone number � � � � � Email address � � � � checked above. (Enter amount from Schedule A � � Schedule B � � � � � � � � � � � � Address � Number and street � PO Box � Fax number � � Email address � � � American LegalNet, Inc. www.FormsWorkFlow.com Each nonparticipating manufacturer selling cigarettes to consumers within Connecticut, whether directly or through a distributor, dealer, or similar intermediary or intermediaries, must Connecticut and other settling states, place the required amount Form TPM-1, . For more information on completing this form, see Announcement 2018(5), 2018 www.ct.gov/DRS to download and print Connecticut tax forms and publications.No later than 30 days after the end of each quarter, the nonparticipating manufacturer must place the required amount of money into a by the to the following address: � � Finance Department � � � � � � � For further information contact: � � � To be completed by a nonparticipating manufacturer- � �. ................................................. 1. Brand � Yes � No � Yes � No � Yes � No � Yes � No � Yes � No � Yes � No � Yes � No Stamper - � �. .................................................. 1.Brand American LegalNet, Inc. www.FormsWorkFlow.com