Form 73a420 - Monthly Report Of Cigarette Wholesaler Page 4
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473A420 (2-12)
Page 4
SCHEDULE D
NONPARTICPATING MANUFACTURER
WHOLESALER’S MONTHLY REPORT OF
CIGARETTES
STAMPED FOR KENTUCKY
WHOLESALER
CITY
LICENSE NUMBER
FOR MONTH/YEAR
INSTRUCTIONS:
List the nonparticipating manufacturer for each brand that was stamped with a Kentucky cigarette stamp during the month. This should be done by all wholesalers. If
the cigarettes were not purchased directly from the manufacturer, that information may be obtained from the carton or pack of cigarettes. If the cigarettes were received
from another wholesaler who has already affixed the Kentucky cigarette stamp, do not list on this report. If you do not stamp any cigarettes during the month from a
nonparticipating manufacturer, enter “NONE” in the boxes. Complete all boxes required.
Attach a copy of all purchase invoices covering these shipments to this report.
Nonparticipating Manufacturer Has a
Number of Individual
Name and Address of Seller
Qualified Escrow Account
Brand
Nonparticipating
Cigarettes Stamped
From Whom Brand Was Purchased
(Indicate if Known)
Name
Manufacturer’s Name and Address
with a Kentucky
(If Different from Original Manufacturer)
Cigarette Stamp
Yes
No
The Kentucky Department of Revenue provides a current list of participating manufacturers on its tobacco Web site If you would like a copy
mailed or need assistance, call (502) 564-6823.
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