Dbpr Form Ab&t 4000a-245 - Manufacturer'S Monthly Report For Distribution Of Samples - Department Of Business And Professional Regulation - Florida

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DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-245
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-1022
MANUFACTURER'S MONTHLY REPORT FOR
DISTRIBUTION OF SAMPLES
Manufacturers disposing of sample cigarettes and/or tobacco products other than cigars within or over Florida must file this report showing
activity for the month. 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". Distributors paying $50,000 or more in excise taxes per year must remit tax
payments through electronic funds transfer, as prescribed by Chapte 210.021, Florida Statutes.
(
)
Name
Phone Number
Permit No.
Address
City
State
Zip
Month Reported
Yr
Reporting Period
through
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 AND COMPUTATION OF TAXES
Number of cigarettes @ 16.95 mils
( $0.01695
) each
Tobacco wholesale sales price @
25%
of such price
(Valuation of manufacturer's price to wholesaler for sample
products other than cigars)
Total of taxes to be remitted with this report
003044
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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