Dbpr Form Ab&t 4000a-200-1 - Cigarette Distributing Agent'S Report
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1DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-200-1
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-1022
CIGARETTE DISTRIBUTING AGENT'S REPORT
Prepare in TRIPLICATE. Submit ORIGINAL and FIRST COPY to the AUDITING OFFICE of the DIVISION OF ALCOHOLIC BEVERAGES AND
TOBACCO. SECOND COPY is to be retained by the licensee. This report and payment must be filed in accordance with the provisions of
Chapter 210, Florida Statutes, on or before the tenth day of the month following the month being reported. Make remittances payable to the
"Division of Alcoholic Beverages and Tobacco".
Name
Phone No. (
)
Permit No.
Address
City
FL Zip
Month Reported
Reporting Period
through
Yr
This report is true and correct to the best of my knowledge and belief and is submitted under penalty of perjury.
Typed or Printed Name
Authorized Signature
SUMMARY OF TRANSACTIONS
20s
25s
1.
Beginning Balance
2.
Received
3.
Returns From Distributors
4.
Total To Be Accounted For (Lines 1, 2, & 3)
5.
Shipped In-State
6.
Shipped Out-of-State
7.
8.
Total Accounted For (Lines 5, 6, 7)
9.
Ending Balance
10.
Actual Inventory
11. Over / Short (Lines 9 minus line 10)
DAB&T USE ONLY
REPORT RECEIPT
In'ls
PAYMENT VERIFICATION
In'ls
FIELD REVIEW
In'ls
CENTRAL PROCESSING
In'ls
Postmark Date
Receipt No.
Initial Review Date
Initial Receipt Date
Delivery Date
Payment Date
Amended Date
Completed Date
Delinquency Action
Excise Tax Paid
Amended Amount
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