to Distributor Name: Contact Name: Distributor Address: Tel Number: City, State, Zip: Contact email: License Number: Brand name Number of cigarettes sold within Maine Ounces of RYO tobacco sold within Maine Participating manufacturer name Entity from whom product was purchased Who paid Maine tax/ affixed tax stamps? U - us A - another To whom did you sell product? D - distributor (name) R - retailer Brand name Number of cigarettes sold within the state Ounces of roll-your own tobacco sold within the state Non-participating manufacturer name Entity from whom product was purchased Who paid Maine tax/ affixed tax stamps? U - us A - another To whom did you sell product? D - distributor (name) R - retailer NON-PARTICIPATING MANUFACTURERS Maine Attorney Generalattn: Tobacco Program6 State House StationAugusta, ME 04333-0006tel: (207) 626-8494 2019 Distributor Quarterly Report of Tobacco Sales in Maine 2019 reporting quarter: PARTICIPATING MANUFACTURERS return form via email to laurie.simpson@maine.gov American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com