Sd Eform 0894 - Standing Rock Sioux Tribe Monthly Cigarette Sales Page 5
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5CHEYENNE RIVER 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 Cheyenne River 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
8 pks/crt
10 pks/crt
Rural Area, Dewey County, SD
Firesteel, SD
Isabel, SD
Glencross, SD
Timber Lake, SD
White Horse, SD
La Plant, SD
Ridgeview, SD
Parade, SD
Lantry, SD
Eagle Butte, SD
Rural Area, Ziebach County
Dupree, SD
Glad Valley, SD
Redelm, 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 Cheyenne
River 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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PRINT FOR MAILING
EXIT
CLEAR FORM
SEND ELECTRONICALLY
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