Form Tob-101 - Delivery Sales Of Cigarette/other Tobacco Products To Persons In Indiana Form - Indiana Department Of Revenue

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Mail To: Indiana Department of Revenue

Indiana Department of Revenue

TOB-101

Criminal Investigation Division

Delivery Sales of Cigarette/Other Tobacco Products

Indiana Government Center North

State Form 51418

100 North Senate Avenue RM N181

(R/03-05)

to Persons in Indiana

Indianapolis, IN 46204-2253

Delivery Sales of cigarettes/other tobacco products into the State of Indiana for the month ending __________/200__.

Due Date: 10th day of the calendar month following the month in which Cigarettes/Other Tobacco Products were shipped into the State of Indiana and where the appropriate

tobacco taxes were not collected from the purchaser.

Merchants Name

Federal FEIN or SSN

Mailing Address

Telephone Number

City

State

Zip Code

E-Mail Address

Contact Person

Title

Contact Telephone Number

Attach additional sheets as needed.

Cigarette

Invoice Date

Invoice

Purchaser’s

Product

Other Tobacco Products

Number

Name

Address

Brand

Number of

Sales Price

Wholesale Price Sales Price

Cigarettes

Note: Your own form may be attached if it contains all the necessary information. (For example, a Computer Generated Report)

Delivery Sale -

A delivery sale is defined in IC 24-3-5-1 as: A transaction for the purchase of tobacco products in which an offer to purchase tobacco products is made:

(1) electronically using a computer network (as defined in IC 35-43-2-3); (2) by mail; or (3) by telephone; and acceptance of the offer results in delivery of

tobacco products to a named individual at a designated address.