Form Rpd-41240 - Report Of Imported Cigarettes Page 2

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Part 1 – Report of Imported Cigarettes Bought and Sold
Distributor’s Business Name
Reporting period:
Page ______ of _______
Number of cigarettes
Purchaser of Imported Cigarettes Sold
Supplier of Imported Cigarettes Purchased
Brand Name
Brand Style
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Under penalty of perjury I declare that I have examined this return and the information reported on this form and any attached supplements is true, correct and complete.
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Signature
Date

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