Form Dr 1285 - Licensed Distributor Reporting Form For Cigarettes Sales Of Non-Participating Manufacturer Brands

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DR 1285 (04/30/07)

LICENSED DISTRIBUTOR REPORTING FORM FOR CIGARETTES

COLORADO DEPARTMENT OF REVENUE

SALES OF NON-PARTICIPATING MANUFACTURER BRANDS

EXCISE TAX ACCOUNTING SECTION

1375 SHERMAN STREET

Provide the following information regarding:

DENVER CO 80261

(303) 205-8211 EXT 6848

• Cigarettes manufactured by a Non-participating Manufacturer that bear a Colorado cigarette tax stamp

FAX (303) 205-8215

• Roll-your-own tobacco manufactured by a Non-participating Manufacturer sold in Colorado

SEE REVERSE FOR INSTRUCTIONS

DUE DATE: 20

DAY OF EACH MONTH FOLLOWING

THE CLOSE OF THE REPORTING MONTH

Reporting Month and Year

Business Name

Business Address

Business Registration Number

Contact Person

Telephone Number

FAX Number

Email Address (required)

Brand Name

Number of ciga-

Number of sticks

Non-participating manufacturer

Name and address of

Name and address

rettes (sticks) sold

converted from

name

the person(s) from

of the first importer of

within Colorado

ounces of roll-your-

and address

whom each brand

foreign manufactured

own tobacco sold

was purchased

brands

within Colorado

I certify that the above-stated information is true and correct.

Signature

Date

Print Name and Title

Page _______ of ________

Failure to file this report as required may result in the revocation of your cigarette and/or tobacco products license(s) for a period of two years.

Distributor is responsible to notify the Department of any changes to address, telephone number, FAX number or E-mail address.

Under Regulation 39-28-303(2)(c), an email address must be provided to the department for the purposes of the distributor receiving notice of any addition or removal from the

Colorado Certified Brands Directory (CBD). Any subsequent change of the email address shall be submitted to the department by email or in writing within five (5) business days

after the change of the email address. You can notify the department at the address or the fax number at the top of this form or at mastersettlement@spike.dor.state.co.us