Form 801-R - Tobacco Products Tax Return Form Page 5
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1
2
3
4
5801
)
for Form
TOB-SCHEDULE D (
R
S
D
CHEDULE
TIN / SSN : # ____________________
A
C
N
I
O
S
C
LL
IGARS
OT
NCLUDED
N
CHEDULE
Page ____ of ____
S
D
P
I
P
II
(
CHEDULE
CONSISTS OF
ART
AND
ART
)
Taxpayer Name
Reporting Month
PART I.
5
0.05
CIGARS RETAILING FOR
CENTS ($
) OR LESS
Date
Name of Supplier
Invoice Number
Quantity (Number of Cigars)
1. Total Number of Cigars Purchased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Tax Due (Divide Total in 1. by 3 and then multiply by $.044) . . . . . . . . . . . . . . . . .
[Enter Here & on Line 1 from Form 801R] :
PART II.
5
0.05
CIGARS RETAILING FOR MORE THAN
CENTS ($
)
Date
Name of Supplier
Invoice Number
Quantity (Number of Cigars)
3. Total Number of Cigars Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Tax Due (Total in 3. times $.044) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Total Tax Due on Cigars (Add Lines 2 and 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Enter here and on Line 4, Form 801R)
TOB - Form 801 - R
ONTC
Schedule D
Revised: 2/12/2002
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