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Form Dr 1284 - Licensed Distributor Reporting Form For Tracking Non-Tax Paid Transfers Of Non-Participating Manufacturer Cigarette Brands For Escrow Purposes

DR 1284 (04/09/09)

Colorado department of revenue

excise tax accounting section

1375 sheRman stReet

liCensed distributor reporting form for traCking

DenveR co 80261

(303) 205-8211 ext 6848

non-tax paid transfers of non-partiCipating

Fax (303) 205-8215

manufaCturer Cigarette brands for esCrow purposes

identifying information

due date: 20th of each month

Reporting Month and Year

Business Name

Business Address

Business Registration Number

Contact Person

Telephone Number

Fax Number

Email Address (required)

npm non-tax paid product transferred within or exported from Colorado—Provide the following information regarding:

•

cigarettes and roll-your-own tobacco (RYo) manufactured by a non-Participating manufacturer that was transferred to another distributor in colorado

•

cigarettes and roll-your-own tobacco manufactured by a non-Participating manufacturer that was exported to a recipient outside of colorado

Brand name

number of

number of ounces (RYo)

number of sticks

name and address of

name and address

Was transaction a

cigarettes (sticks)

RYo (oz. ÷ .09)

non-participating

of transfer (in-state) or

transfer or an export?

manufacturer

export (out-of-state)

product recipient

❒

transfer

❒

export

state

❒

transfer

❒

export

state

❒

transfer

❒

export

state

❒

transfer

❒

export

state

❒

transfer

❒

export

state

i certify that the above-stated information is true and correct.

signature

Date

Print name and title

Page ____of____

Failure to file this report as required may result in the revocation of your cigarette and/or tobacco products license(s) for a period of two years.

distributor is responsible to notify the department of any changes to address, telephone number, fax number or email address.

Under Regulation 39-28-303(2)(c), an email address must be provided to the department for the purposes of the distributor receiving notice of any addition or removal from the

Colorado Certified Brands Directory (CBD). Any subsequent change of the email address shall be submitted to the department by email or in writing within five (5) business days

after the change of the email address. You can notify the department at the address or the fax number at the top of this form or at mastersettlement@spike.dor.state.co.us