Certification of Compliance and Affidavit by Nonparticipating Manufacturer

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 financial institution complete and sign Part II before a notary public. The Agent must list Cigarettes (sticks) sold to consumers within Connecticut during the calendar quarter checked on Page 1. Enter brand, purchaser’s name, and the number of cigarettes (sticks) sold to consumers within Connecticut, whether directly or through a distributor, dealer, or similar intermediary or intermediaries, during calendar quarter. Also report the purchaser’s “stamper” status to the right of Column B. Attach additional sheet(s) as necessary to provide a complete response.