Sd Eform 0894 - Standing Rock Sioux Tribe Monthly Cigarette Sales Page 4

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PINE RIDGE SIOUX TRIBE
MONTHLY CIGARETTE SALES
Mail to: Department of Revenue, Special Tax Division, 445 E Capitol Ave Pierre, SD 57501-3100
Licensed cigarette distributors are herewith required to file reports of monthly cigarette sales into the Pine Ridge Sioux
Reservation. All reports shall reflect the total number of cartons sold in each period.
Cartons of cigarettes sold in the month of _______________________________________________ , 20__________
Number of Cartons
Retailers In:
20
25
25
8pks/crt
10 pks/crt
Rural Area, Bennett County
Allen, SD
Harrington, SD
Martin, SD
Swett, SD
Tuthill, SD
Vetal, SD
Rural Area, Shannon County
Denby, SD
Kyle, SD
Manderson, SD
Oglala SD
Pine Ridge, SD
Porcupine, SD
Sharps Comer, SD
Wounded Knee, SD
Rural Area, Jackson County
Wanblee, SD
Hisle, SD
Long Valley, SD
Total Number
0
0
0
I, the undersigned, certify that this return is an accurate and true report of all cartons of cigarettes sold into the Pine Ridge
Sioux Reservation during the month indicated above.
Signed: _________________________________________
Title: __________________________________________
Firm: __________________________________________
Address
: ____________________________________________
NOTE: This report is due prior to the 10th of each month listing all sales for the previous month and mailed to the address listed above.

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