Schedule A-5 - Tobacco Products Tax Form - Department Of Revenue Services State Of Connecticut
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1Department of Revenue Services
Schedule A-5
State of Connecticut
PO Box 5018
Hartford CT 06102-5018
Tobacco Products Tax
(Rev. 10/11)
Record of cigars in excess of $1.00 per cigar purchased, imported, received, acquired, or manufactured in Connecticut.
Name
Period ending
Address
CT Tax Registration Number
Enter the total of Schedule A-5 on Form OP-300, Tobacco Products Tax Return, Line 13. Attach Schedule A-5 to the return.
Date Received,
Purchased From, Imported To,
Seller’s
Invoice Number
Number
Imported,
or Manufactured
FEIN
of Cigars
or Manufactured
Total
Enter this amount on Form OP-300, Line 13.
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