Form Mt - Cigpaper - Cigarette Paper And Tube Sales Monthly Tax Reporting Form - 2009

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REVENUE DIVISION
STATE OF ARKANSAS
Miscellaneous Tax Section
Department of Finance
P. O. Box 896 - Room 2240
th
1816 W. 7
Street
and Administration
Little Rock, Arkansas 72203
Phone: 501-682-7185
FAX: 501-683-3699
Mary.Roddy@dfa.arkansas.gov
CIGARETTE PAPER AND TUBE SALES
MONTHLY TAX REPORTING FORM
1. Wholesale Tobacco Permit #: _______________ 2. Report Month/Year: ________/________
3. Taxpayer: __________________________________________________________________________________
4. Mailing address:
_______________________________________________________________________________________________
(Street address / P.O. Box)
(City)
(State)
(Zip Code)
5. Contact Person: __________________________ 6. Telephone #: _____________ 7. Fax #: ______________
8. Email address:
_________________________________________________________________________________________________
Col. A
Col. B
Col. C
Col. D
Col. E
Line
Descriptio
Packages
Tubes – 100 CT.
Tubes – 200 CT.
Tubes – 400 CT.
Total
n
9.
# of items
10.
Rate
X $0.25
X $0.78
X $1.56
X $3.12
11.
Tax due
$
$
$
$
$
12.
TOTAL TAX DUE (Line 11, Col. E)
$
Cigarette Paper/Tubes Tax Report is due on or before the 15th of the month
Make check payable to: Department of Finance and Administration
Mail report with payment to: Miscellaneous Tax Section
PO Box 896, Room 2340
th
1816 W. 7
Street
Little Rock, Arkansas 72203
I declare under penalties prescribed by the Arkansas Tobacco Tax Act of 1977 and the Arkansas Tax Procedures Act
that this document, along with all supporting schedules are true, correct, and complete.
_______________________________
_________________________________
_____/_____/_____
(Signature)
(Printed name)
(Date)
OFFICIAL USE ONLY
5391
Class Code:
Check No.: _____________
Check Amt: ____________
MT – CIGPAPER (revised 3/09)

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