Form Ct-39 - Record Of Cigarette Stamps Purchased Resident Distributor
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1
2Department of Revenue Services
Form CT-39
PO Box 5031
Hartford CT 06102-5031
Record of Cigarette Stamps Purchased
(Rev. 07/11)
Resident Distributor
For the month of _______________________________________________________ 20 _______
Name of distributor ___________________________________________________ CT Tax Registration Number ____________________
Address of distributor ____________________________________________________________________________________________
(Street)
(City or town)
(State)
(ZIP code)
Attach to the distributor’s monthly report. The total face value should agree with the amount reported on Line 2 of Form CT-15, Monthly Tax
Stamp and Cigarette Report, Resident Distributor.
Quantity of Stamps
Purchase
Total
Invoice Number
$ 4.25
Face Value
Date
$ 3.40
Subtotals for this page
Subtotals from reverse
Totals
$
Continue on reverse if necessary.
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