South Dakota Cigarette P.a.c.t. Act Report Template - Dor Tobacco
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2South Dakota Cigarette P.A.C.T. Act Report
Step 1: Identify your business
Name:
Reporting period: __ __/__ __ __ __
_________________________________________________
(Month/Year)
Address:
License no.: ____________________________
_______________________________________________
Number and street
EIN:____-______________
________________________________________________
City
State/Province
ZIP
(FEIN)
Country/Territory: ___________________________________
Phone: (_____)______- ___________ Ext:__________
Contact name: ______________________________________
Email address:___________________________________
S
tep 2:
Identify your sales into Sou
th Dakota
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:________________________________________ Cigarettes (sticks):_______________________
Brand:__________________________________ UPC:__________________________________________
Buyer: _________________________________ Address:________________________________________ License #:_____________________________
________________________________________ FEIN: _________________________________
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:________________________________________ Cigarettes(sticks):________________________
Brand:_____________________________
UPC: _________________________________________
Buyer:
_____________________________
Address:________________________________________ License #:_____________________________
________________________________________ FEIN: _________________________________
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________ Cigarettes (sticks):________________________
Brand:_____________________________
UPC: _________________________________________
Buyer:
_____________________________
Address:________________________________________ License #:_____________________________
________________________________________ FEIN: _________________________________
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:________________________________________ Cigarettes (sticks):________________________
Brand:_____________________________
UPC:_________________________________________
Buyer:
_____________________________
Address:________________________________________ License #:_____________________________
________________________________________ FEIN: _________________________________
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________ Cigarettes (sticks):________________________
Brand:_____________________________
UPC:_________________________________________
Buyer:
_____________________________
Address:________________________________________ License #:_____________________________
________________________________________ FEIN: _________________________________
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report, and, to the best of my knowledge, it is true, correct, and complete. I also
state that such information is taken from the books and records of the business for which this report is filed.
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
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