Maine’s Quarterly Reporting Form for Tobacco Sales [required to be completed by distributors pursuant to 22 MRSA §1580-L(9)] Reporting Period , 2008 through , 2008 Return the completed form 20 days after the close of the reporting period to: Laurie Simpson Office of Attorney General 6 State House Station Augusta, Maine 04333-0006 Please provide the following information with respect to cigarettes that were stamped for sale within Maine AND roll-your-own tobacco. To see a list of manufacturers/brands that are certified to be sold in Maine, visit the Maine Attorney General’s website at www.maine.gov/ag/?r=healthissues and click on the “Tobacco Manufacturers” link. Your Business Name and Address: ___________________________________________________________________________ Contact Person:_________________________________________ Telephone: ___________________________ PARTICIPATING MANUFACTURERS Manufacturer Name and Address (If Known) (d) Brand Name (a) Number of Cigarettes Sold Within State (b) Ounces of Roll-Your-Own Tobacco Sold Within State (c) American LegalNet, Inc. www.FormsWorkflow.com NON-PARTICIPATING MANUFACTURERS Manufacturer Name and Address (If Known) Brand Name Number of Cigarettes Sold Within State Ounces of Roll-Your-Own Tobacco Sold Within State Please attach additional pages as necessary. I certify that the above-stated information is true and correct. ______________________________________________ Signature ______________ Date American LegalNet, Inc. www.FormsWorkflow.com