Office of the Vermont Attorney General

TJ Donovan, Vermont Attorney General

Prescribed Products Refund Form

Office of Vermont Attorney General
109 State Street
Montpelier, VT 05609-1001

REFUND REQUESTOR

Manufacturer: *

Make Payable to: *

Address: *

City: *

State: *

Zip Code: *

Contact Name: *

Title: *

Telephone: *

Email: *

Fed ID #: *

INFORMATION ON ORIGINAL CHECK

Manufacturer: *

Check Number: *

Check Amount $: *

Reporting Period *

CERTIFICATION
I hereby certify that the above manufacturer had no prescribed products disclosures to report for the period state above.

Compliance Officer Name *

Compliance Officer Title *

Compliance Email Address *

Date *

Refunds of registration fees may not be reviewed for approval and processing until 60 days after the reporting deadline

Please note: Anything you submit to the Attorney General’s Office may be subject to disclosure under Vermont’s Public Records Act.

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109 State St
Montpelier, VT 05609

(802) 828-3171

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Vermont’s lobbyist registration and disclosure law applies to certain communications with and activities directed at the Attorney General. Prior to any interactions with the Office of the Vermont Attorney General, you are advised to review Title 2, Sections 261-268 of the Vermont Statutes Annotated, as well as the Vermont Secretary of State’s most recent guide to compliance, available at https://www.sec.state.vt.us/elections/lobbying.aspx.