Schedule A-4 - Tobacco Products Tax - Nonresident Distributor
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1Department of Revenue Services
Schedule A-4
State of Connecticut
Excise/Public Services Taxes Subdivision
Tobacco Products Tax - Nonresident Distributor
25 Sigourney Street
Hartford CT 06106
Record of snuff tobacco products imported into Connecticut
Enter the total of Schedule A-4 on Line 9 of Form OP-300, Tobacco Products Tax Return . Attach Schedule A-4 to the return.
(Rev. 01/02)
Name ___________________________________________________
Period Ending __________________
CT Tax Registration Number _________________________
Address __________________________________________________________________________________________________________________________________________
Weight Each
Total Weight
Tax
Invoice Number
Date
Imported To
Brand Name
Quantity
(in ounces)
(Col. 5 x 6)
(Col. 7 x 0.40)
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8
Report this amount on Line 9 of Form OP-300
Total
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