Form Ct-Txchg - Cigarette Inventory Floor Tax April 2004 Page 2

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Section 3 – Wholesaler, retail store and cigarette vending machine inventories recap

Business license ID _____________________________________

Business name _________________________________________ Phone _________________________

(A)

(B)

(C)

(D)

(E)

4/30/03 inventory exceeding

Ending inventory on

Ending inventory for income tax reporting year beginning

tax year ending inventory

Cigarette Tax

Total tax

Description

12:01am, 4/30/03

__________ and ending __________

(A – B = C)

increase

(C X D = E)

Number of stamped

packs containing 20

cigarettes

$ 0.52

Number of stamped

packs containing 25

cigarettes

$0.65

Number of unaffixed

decals for packs

containing 20

cigarettes

$ 0.52

Number unaffixed

decals for packs

containing 25

cigarettes

$0.65

Total this page – Total column E add values from this page ...........................................................................................................................................

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