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Compliance Officer Form

Vermont Office of Attorney General

109 State Street
Montpelier, VT 05609-1001

Due Date: April 1, 2023

Section 1: Manufacturing Company

Contact Information
Type of Manufacturing, (Check all that apply)

Section II: Compliance Officer

Contact Information

Section III: Data Collection and Reporting, If different from Compliance Officer, check if same

Section IV: Filing

Report
Do you intend to submit data that would have been (or was) submitted to the federal government under the Patient Protection and Affordable Care Act?

Section V: Declaration

I certify that the information stated by me in this disclosure is true and accurate to the best of my knowledge. I understand that providing false information or omission of information is unlawful.

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