FORM 1074
STATE OF DELAWARE
DIVISION OF REVENUE
RESIDENT WHOLESALE DEALER'S
MONTHLY REPORT OF
FOR OFFICE USE ONLY REVENUE CODE: 0035-02
CIGARETTE AND CIGARETTE TAX STAMPS
NAME:
EMPLOYER IDENTIFICATION NUMBER:
Reset
ADDRESS:
REPORT FOR MONTH OF:
CITY:
TELEPHONE NUMBER:
Print Form
STATE:
ZIP CODE:
FAX NUMBER:
NO NON-PARTICIPATING MANUFACTURER PRODUCTS SOLD INTO DELAWARE: [ ] NO
[ ] IF YES, COMPLETE SCHEDULE NPM
PACKAGES OF CIGARETTES
SCHEDULE
CIGARETTE ACCOUNT
20'S
25'S
TOTAL
ON HAND AT BEGINNING OF MONTH (STAMPED)
ON HAND AT BEGINNING OF MONTH (UNSTAMPED)
1074-A
RECEIVED FROM MANUFACTURERS (STAMPED)
1074-A
RECEIVED FROM MANUFACTURERS (UNSTAMPED)
1074-B
RECEIVED FROM OTHER THAN MNFR (STAMPED)
THIS REPORT AND SCHEDULES 1074A, 1074B,
1074-B
RECEIVED FROM OTHER THAN MNFR (UNSTAMPED)
1074C,1074D, 1074E AND NPM-CIG
SOLD IN DELAWARE
ARE TO BE FILED WITH THE
1074-C
SOLD TO DELAWARE AFFIXING AGENTS
DELAWARE DIVISION OF REVENUE,
1074-D
SOLD OUTSIDE DELAWARE
P.O. BOX 2340, WILMINGTON, DE 19899, ON OR
1074-E
SOLD TO EXEMPT ORGANIZATIONS IN DELAWARE
BEFORE THE 20TH DAY OF EACH MONTH FOR
NPM
PRODUCTS PURCHASED FROM NPM
THE PRECEDING MONTH, BY EVERY
DESTROYED, LOST OR STOLEN (STAMPED)
WHOLESALER IN DELAWARE. WHOLESALE
DESTROYED, LOST OR STOLEN (UNSTAMPED)
DEALERS WHO HAVE A DELAWARE PERMIT BUT
RETURNED TO MANUFACTURERS (STAMPED)
WHO ARE SITUATED OUTSIDE DELAWARE MUST
RETURNED TO MANUFACTURERS (UNSTAMPED)
FILE MONTHLY REPORTS ON FORM 1075
INVENTORY AT END OF MONTH (STAMPED)
INVENTORY AT END OF MONTH (UNSTAMPED)
STAMP ACCOUNT
STAMPS
$1.15
$1.44
ON HAND BEGINNING OF MONTH (UNAFFIXED)
RECEIVED FROM DOR DURING MONTH
SUBTOTAL
STAMPS AFFIXED DURING MONTH
(
) (
)
ON HAND AT END OF MONTH (UNAFFIXED)
AFFADAVIT:
I hereby swear under penalty of perjury that the foregoing return has been examined by me and that all information contained herein, including any accompanying schedules or statements is true and correct; and that this
constitutes a complete return for the month stated, pursuant to law. I also swear that the licensee is in compliance with the UNFAIR CIGARETTE SALE ACT, Chapter 26 of Title 6 of the Delaware Code.
_______________________________________________
_____________________________
______________________
SIGNATURE OF LICENSEE OR OFFICER THEREOF
TITLE
DATE
(Revised 07/30/07)