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Form B-A-101cr - Application For Other Tobacco Products Excise Tax Refund For North Carolina Tax-Paid Other Tobacco Products Returned To Manufacturer

B-A-101CR

Application for Other Tobacco Products

Web

Excise Tax Refund for North Carolina Tax-Paid

9-09

Other Tobacco Products Returned to Manufacturer

North Carolina Department of Revenue

DOR Use Only

Return for Month Ended

(MM-DD-YY)

Legal Name (First 35 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)

FEIN or SSN

Trade Name

Mailing Address

NCDOR ID/License Number

City

State

Zip Code

Name of Contact Person

Phone Number

State of Domicile

Computation of Refund for North Carolina Tax-Paid Other Tobacco Products On or After September 1, 2009

1. Total Cost Price of Other Tobacco Products Returned to Manufacturer

Cost price is the price paid for the products before any discount, rebate, or allowance.

(Attach copies of invoices or equivalent information.)

12.8%

Refund Rate for Returned Other Tobacco Products

Refund Due

Multiply Line 1 by Line 2

Discount

Multiply Line 3 by 2% if Form BA-101 was timely filed; otherwise enter zero.

Total Refund Due

Line 3 minus Line 4

Signature:

Title:

Date:

I certify that, to the best of my knowledge, this return is accurate and complete.

An original manufacturer’s affidavit and a copy of the manufacturer’s credit memo MUST be attached to this

application. Absent conclusive proof that other tobacco products were returned to the manufacturer at the tax rate effective

on or after September 1, 2009 will result in the denial of refund.

North Carolina Department of Revenue, Tobacco Products Unit, PO Box 25000, Raleigh, North Carolina 27640-0001

Form B-A-101cr - Application For Other Tobacco Products Excise Tax Refund For North Carolina Tax-Paid Other Tobacco Products Returned To Manufacturer