Non-Participating Manufacturer Reporting Form 2001

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Non-Participating Manufacturer
State of Washington
Return the completed form 25 days after the close
Department of Revenue
Special Programs Division
Reporting Form
of the reporting month.
PO Box 47477
Olympia WA 98504-7477
Instructions on reverse side
Please complete this schedule in full and mail to:
Washington State Department of Revenue,
Please provide the following information with respect to cigarettes sold that were manufactured
Special Programs Division, PO Box 47477,
by a Non-Participating Manufacturer (NPM).
Olympia WA 98504-7477
Tax Reporting
Account No:
/
/
Name:
Reporting Month/Yr:
mm/yy
No. of
Ounces of Roll-
Cigarettes
Your-Own
Name & Address of the Person
Name & Address of the First
Sold in
Tobacco Sold in
Non-Participating Manufacturer
From Whom Each Cigarette
Importer of Foreign
Washington
Washington
Brand Name
Name & Address
Was Purchased
Manufactured Cigarettes
(a)
(b)
(c)
(d)
(e)
(f)
This report is subject to future verification by the Department of Revenue.
Signature:
Phone:
Date:
REV 82 2107-2 (3-26-01)

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