Monthly Report Of Unstamped Tobacco Products Form
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1
2A
D
R
TOB: NG
LABAMA
EPARTMENT OF
EVENUE
Rev. 11/09
S
, U
& B
T
D
Month of ______________________________, _________
ALES
SE
USINESS
AX
IVISION
T
T
S
OBACCO
AX
ECTION
Name _____________________________________________________________
P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Address ___________________________________________________________
Monthly Report of Unstamped Tobacco Products
Alabama
City _____________________________________,
ZIP ___________
Contact Person ______________________________________________________
Purchased by Alabama National Guard Armories
from wholesale dealers in tobacco products who are duly qualified with the State of
–
Telephone Number (
)
Alabama. This report must be filed with the Alabama Department of Revenue no later than
the 10th of the month for the previous month’s activity. The report must be accompanied by
Reset
the yellow copy of the Tobacco Tax Exemption Certificate to substantiate the purchase. See
additional instructions on reverse side.
CIGARETTES ONLY
OTHER TOBACCO
INVOICE
CERTIFICATE
INVOICE
TAX VALUE
FROM WHOM RECEIVED AND ADDRESS
CHEWING
SMOKING
LITTLE
NUMBER OF
(# OF
SNUFF
R-Y-O
CIGARS
DATE
NUMBER
NUMBER
TOBACCO
TOBACCO
CIGARS
CIGARETTES
CIGARETTES
TAX VALUE
TAX VALUE
TAX VALUE
TAX VALUE
TAX VALUE
TAX VALUE
X $0.02125)
Total
Under penalties of perjury, I hereby certify that this report is true and correct.
Permanent Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
Retired Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
NATIONAL GUARD ARMORY
Temporary Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
Other (Explain)__________________________________ ________________________
Signature __________________________________________________________
______________________________________________ ________________________
Signature of person making purchase and report
______________________________________________ ________________________
Date ______________________________________________________________
TOTAL STRENGTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________________________
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