Form 69-302 - Certificate Of Tax Exempt Sale - 2004
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169-302
(Rev.12-01/4)
b.
TEXAS CERTIFICATE OF TAX EXEMPT SALE
—UNSTAMPED CIGARETTES, UNTAXED CIGARS, AND/OR
• COMPLETE A SEPARATE FORM FOR EACH TRANSACTION
UNTAXED TOBACCO PRODUCTS
• PLEASE TYPE OR PRINT.
Under Ch. 559, Government Code, you are entitled to review, request, and correct information we have on file about you, with limited exceptions in accordance
with Ch. 552, Government Code. To request information for review or to request error correction, contact us at the address or toll-free number listed on this form.
SOLD BY TEXAS PERMITTED DISTRIBUTOR
a. Taxpayer number
c. Filing period
Month ending _______________________
d. Name of distributor
e. Address of distributor
City
State
ZIP code
PURCHASED BY OR DELIVERED TO
f. Name
g. Address
City
State
ZIP code
h. Purchaser or authorized agent requesting shipment
i. Date of delivery of shipment (Month, day, year)
j. Invoice number covering shipment
CONTENTS OF SHIPMENT - Number of cigarettes and cigars - value of tobacco
NUMBER OF CIGARS
1.
2.
TOBACCO
CLASS F
3.
4.
5.
CLASS D
6.
CLASS A
CLASS B
CIGARETTES
CLASS C
Cigars weighing 3 pounds
Cigars weighing 3 pounds
Tobacco including smoking
Little cigars with a weight
per thousand of
Cigars weighing 3 pounds
Number of cigarettes
per thousand of natural
and chewing tobacco
of not more than 3
substantial non-tobacco
per thousand selling for 3.3
leaf selling for over 3.3
filler selling for over 3.3
pounds per thousand
(Mfr’s gross list price)
cents or less
cents each
cents each
$
PURCHASER SECTION - Purchaser MUST complete this section.
I hereby certify that no tax is due on the purchase of the merchandise itemized above, since the sale of this merchandise is being made to a federal
instrumentality, and I certify that I am authorized to sign this certificate on behalf of the purchaser named above.
7. Name of authorized agent (Please print)
8. Title
➧
sign
here
9.
Service number (Member of armed forces) ___________________________________________
Social security number (Civilian employee) ___________________________________________
DISTRIBUTOR SECTION - Distributor MUST complete this section.
I hereby certify that the sale of the merchandise itemized above is being made to a federal instrumentality.
10. Name of distributor or authorized agent (Please print)
11. Date
➧
sign
here
ORIGINAL - submit with monthly report
COPY - distributor
COPY - purchaser
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