Form Ct-115 - Indiana Cigarette Tax Return - Indiana Department Of Revenue

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CT-115
(10/07)
Do not use this space
Please attach a copy of your invoice
Indiana Cigarette Tax Return
Total retail price of the cigarettes
Important: Tax is due at time of purchase.
1
Name
Social Security Number
Total Number of Packs Purchased
2
Multiply number of packs (Line 2) by 0.995
3
Date of Tax Payment
Date Purchased
If Late Include Interest*
4
Make sure the address below shows through window.
If late, penalty due is 10%, or $5.00,
5
whichever is greater.
Indiana Department of Revenue
6
Total Amount Due (Add Lines 3, 4 and 5)
ATTN: Special Tax Division - CIGTAX
*Contact the Department at 317-615-2564 or go to our Web site
P.O. Box 901
, for the current year interest rate.
Indianapolis, IN 46260-0901
Make your check payable to:
:462060901044:
:462060901044:
:462060901044:
:462060901044:
Indiana Department of Revenue - CIGTAX
Do not send cash as your payment

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