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Form Das-95 - Licensed Cigarette Stamping Agent (Csa) Reporting Schedule For Cigarette Sales In Pennsylvania Of Non-Participating Manufacturer (Npm) Brands

DAS-95 (03-05)

Licensed Cigarette Stamping Agent (CSA) Reporting Schedule

This schedule should be

for Cigarette Sales in Pennsylvania of

attached to your Monthly

Non-Participating Manufacturer (NPM) Brands

Cigarette Stamping Agent

A DEPARTMENT OF REVENUE

BUREAU OF BUSINESS TRUST FUND TAXES

(Instructions on Reverse side)

report due the 20th of the

PO BOX 280909

HARRISBURG, PA 17128-0909

Reporting Month/Year: ______________

month.

(717) 783-9354

Please provide the following information with respect to cigarettes that were made by a Non-Participating Manufacturer (NPM) and that were stamped and sold in Pennsylvania.

_____________________________________

____________

Cigarette Stamping Agent License No:

Amended Form for reporting period (month/year)

__________________________________________________________________________________________________________________________________

Business Name and Address:

Federal EIN:

_________________________________

None (No sales of NPM cigarettes in PA)

___________________________

Telephone:

Fax:

E-mail:

Website:

No. of Cigarettes (Sticks)

Non-Participating Manufacturer Name and Address

Name and Address of the Business/Person(s) From

(If Known)

Whom Each Brand Was Purchased

Brand Name

Stamped and Sold Within PA

(c)

(d)

(a)

(b)

Total of Column b: ______________________________

Page _____________ of _____________

Under penalties of perjury, the undersigned authorized agent of the company states that the company named above verifies that all information contained herein is true and correct, and gives

consent for use of this information to the Office of Attorney General to monitor compliance pursuant to Act 54 of 2000, known as the Tobacco Settlement Agreement Act.

Signature, authorized agent

Printed or Typed Name

Title

Date