Form 801-R - Tobacco Products Tax Return Form Page 4

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801
)
for Form
TOB-SCHEDULE C (
R
S
C
CHEDULE
TIN / SSN : # ____________________
C
W
N
M
T
3
1000
IGARS
EIGHING
OT
ORE
HAN
LBS/
Page ____ of ____
Taxpayer Name
Reporting Month
Date
Name of Supplier
Invoice Number
Quantity (Number of Cigars)
Total No. of Cigars Purchased :
Tax Due (Divide total Cigars by 20 and then multiply by $.089) :
[Enter Here & on Line 3 of Form 801R]
TOB - Form 801 - R
ONTC
Schedule C
Revised: 2/12/2002

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