Brand Specific Report For Cigarette, Little Cigar And Roll-Your-Own Product With Iowa Tax Paid For All Manufacturers Form Page 2

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Page ____ Name __________________________ Permit No. ____________________ April - June2003
Brand Specific Report
Please select type of product listed on THIS page (select only one):
Cigarettes
Little Cigars
Roll-Your-Own
Number of sticks
Street address,
Manufacturer if different
Type of
or ounces with
Purchased from
city, state, zip and country
than purchased from
Manufacturer
Brand
IA tax paid
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___________ ___________
P / N
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___________ ___________
P / N
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___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
________________ ____________________________ ________________
___________ ___________
P / N
TOTAL FOR THIS PAGE
___________
IOWA
70-020b (07/01/03)

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