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Form Com/attd-608-3 - Licensed Wholesaler Address Reporting Form - Maryland, Alcohol And Tobacco Tax Division Page 4

Comptroller of Maryland

Alcohol and Tobacco Tax Division

P. O. Box 2999

Annapolis, Maryland 21404-2999

WHOLESALER’S QUARTERLY REPORT OF SALES OF MARYLAND STAMPED CIGARETTES AND/OR

ROLL-YOUR-OWN (RYO) TOBACCO

BY MANUFACTURER’S BRAND FAMILY

Wholesaler’s Name

License/Registration No.

Quarterly Reporting Period

List all cigarettes stamped with a Maryland tax stamp and all sales of roll-your-own tobacco for the report quarter:

(A)

(B)

(C)

(D)

(E)

(F)

Brand Family/Name

Number of

RYO Equivalent

First Importer if Foreign

Cigarettes

Stick Count

Manufacturer’s Name and

From Whom Purchased

Manufactured Product

Stamped

(At .09 oz. Each)

Address

(Name and Address)

(Packs)

Totals

I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document are true and correct to the best of my

knowledge, information and belief.

Signature

Title: Owner, Partner or Officer

Date

COM/ATTD-608-3

REV. 07/03

Form Com/attd-608-3 - Licensed Wholesaler Address Reporting Form - Maryland, Alcohol And Tobacco Tax Division Page 4