Monthly Jenkins Act Report Form - 2010
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1
2A
D
R
TOB: JEN ACT 8/10
LABAMA
EPARTMENT OF
EVENUE
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
___________
T
T
S
Checked by: ___
OBACCO
AX
ECTION
RESET
P. O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Monthly Jenkins Act Report
(As amended by the PACT Act of 2009)
For the Month of _______________________, __________
COMPANY NAME
FEIN
ADDRESS
SOCIAL SECURITY NUMBER
CITY
STATE
ZIP
E-MAIL ADDRESS
TELEPHONE NUMBER
(
)
–
WEBSITE ADDRESS(ES)
Quantity (Weight) of
Brand:
Cigarettes/Smokeless Tobacco shipped to:
Quantity
Smokeless Tobacco
Invoice
Invoice
Cigarettes/Smokeless Tobacco shipped to:
(Cigarettes,
Number of
Shipper’s Phone
(Weight) of
Shipper’s Name
Shipper’s Address
Date
Number
Name
Roll-Your-Own (R-Y-O)
Cigarettes
Number
Chewing
R-Y-O Tobacco
Street
City
State
Zip
Snuff
and Smokeless)
Tobacco
Total Tobacco (Attach additional sheets as needed):. . . . . . . . . . .
The PACT Act (Prevent All Cigarette Trafficking Act of 2009) amended the Jenkins Act and requires any person
who sells or transfers or ships cigarettes or smokeless tobacco for profit into Alabama must file a memorandum
or invoice with the Department of Revenue (DOR) showing each and every shipment of cigarettes or smokeless
tobacco made into Alabama during the previous calendar month. The memorandum, which is due no later than
the 10th day of each month, must include the quantity of cigarettes or smokeless tobacco.
Signature of Officer or Authorized Person
Print Name
Date
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