Form Rev-1031 As - Schedule "B" Cigarettes Received

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R E V-1031 AS (2-06)
SCHEDULE “B”
Month and Ye a r
CIGARETTES RECEIVED
COMMONWEALTH OF PENNSYLVANIA
(OTHER THAN THOSE WHICH YOU HAVE RECEIVED
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
FROM THE MANUFACTURER & REPORTED ON SCHED-
PO BOX 280909
ULE A-1) (TO BE SUBMITTED WITH FORM REV-1030)
Please Print or Type.
HARRISBURG, PA 17128-0909
CSA Name
Address
Number of Cigarettes Received
Received From
Tax Paid
Non Tax Paid
Bearing Stamps
State
For Department Use Only
Name and Address
(PA Stamped)
(Unstamped)
for Other States
Stamp
Total

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