FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
AU-2O1
NON-RESIDENT WHOLESALER CIGARETTE TAX REPORT
For Period beginning
and ending
NAME
LICENSE No.
20's
25's
Other(
)
TOTAL CIGARETTE PACKAGE SALES
DAMAGED
STAMPED CIGARETTE PACKAGE
INVENTORY (END OF PERIOD)
SALEABLE
B-STAMPS
A-STAMPS
Other(
)
TAX INDICIA PURCHASES:
STAMPS
B-STAMPS
A-STAMPS
TAX INDICIA INVENTORY AT END OF PERIOD:
STAMPS
STAMPED CIGARETTES PACKAGES RETURNED TO MANUFACTURER FOR CREDIT
20's
25's
Other(
)
ACCOUNTS PAYABLE DUE AS OF THE PERIOD END FOR TAX INDICIA PURCHASES:
$
Under penalties of perjury, I declare that I have examined this Report, and to the best of my belief it is true, correct and complete.
SIGNATURE OF COMPANY OFFICER (IN INK)
DATE
NH DEPT OF REVENUE ADMINISTRATION
MAIL
AUDIT DIVISION
TO:
PO BOX 457
CONCORD, NH 03302-0457
AU-201
Rev. 7/05