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Cigarette Paper Self-Assessment Excise Tax Report Form - Arkansas Department Of Finance And Administration

REVENUE DIVISION

STATE OF ARKANSAS

Office of Excise Tax Administration

Department of Finance

Miscellaneous Tax Section

and Administration

Post Office Box 896

1816 West Seventh Street, Room 2340

Little Rock, Arkansas 72203

Phone: (501) 682-7187

Fax: (501) 682-1103

CIGARETTE PAPER

SELF-ASSESSMENT EXCISE TAX REPORT

Name:_________________________________________________________ File #:____________________

Address:__________________________________________________________________________________

(Street)

(City)

(State)

(Zip)

Per Act 817 of 2007, it is unlawful for any person to receive or have in his/her possession for sale, consumption,

or any other purpose, any untaxed tobacco products or unstamped cigarettes unless the tax prescribed by this

Act has been paid directly to the Director by the person in possession of the untaxed tobacco products or

unstamped cigarettes.

The tax shall be in the amount of twenty-five cents (25¢) per package of approximately thirty-two (32)

sheets/tubes.

Cigarette Papers/Tubes

Number of untaxed cigarette paper/tube packages purchased since 7/31/07:

______________

Multiply the number of untaxed packages purchased by:

X .25¢

Cigarette Paper/Tube Excise Tax due (Class code: 5391)

$______________

This completed form and related payment are to be mailed to the Miscellaneous Tax Section address

reflected at the top of this form.

--------------------------------------------------------------------------------------------------------------------------------------

I hereby affirm that I have reviewed my purchases of untaxed cigarette papers and tubes since 7/31/07 and

the above information is true and correct to the best of my knowledge.

Signature:____________________________________________________ SS#: ________________________

Telephone number:_______________________________________________ Date:_____________________

Cigarette Paper Self-Assessment Excise Tax Report Form - Arkansas Department Of Finance And Administration