Form 1075 - Non-Resident Wholesale Dealer'S Monthly Report Of Cigarette And Cigarette Tax Stamps

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FORM 1075

STATE OF DELAWARE

Print Form

DIVISION OF REVENUE

NON-RESIDENT WHOLESALE DEALER'S

MONTHLY REPORT OF

FOR OFFICE USE ONLY REVENUE CODE: 0035-02

CIGARETTE AND CIGARETTE TAX STAMPS

NAME:

EMPLOYER IDENTIFICATION NUMBER:

ADDRESS:

REPORT FOR MONTH OF:

CITY:

TELEPHONE NUMBER:

STATE:

ZIP CODE:

FAX NUMBER:

NO NON-PARTICIPATING MANUFACTURER PRODUCTS SOLD INTO DELAWARE: [ ] NO

[

] IF YES, COMPLETE SCHEDULE NPM

PACKAGES OF CIGARETTES

SCHEDULE

CIGARETTE ACCOUNT

20'S

25'S

TOTAL

1075-A

SOLD IN DELAWARE

1075-B

SOLD TO DELAWARE AFFIXING AGENTS

1075-C

SOLD TO TAX EXEMPT ORGANIZATIONS IN

DELAWARE

NPM

NPM PRODUCTS SOLD IN DELAWARE

RETURNED TO MANUFACTURER (STAMPED)

INVENTORY BEGINNING OF MONTH (STAMPED)

THIS REPORT AND SCHEDULES 1075A, 1075B,

INVENTORY END OF MONTH (STAMPED)

1075C AND NPM-CIG ARE TO BE

STAMP ACCOUNT

STAMPS

FILED WITH THE DELAWARE DIVISION OF

$1.60

$2.00

REVENUE, P.O. BOX 2340, WILMINGTON, DE 19899

ON HAND AT BEGINNING OF MONTH (UNAFFIXED)

ON OR BEFORE THE 20TH DAY OF EACH MONTH

RECEIVED FROM DELAWARE DIVISION OF REVENUE

FOR THE PRECEDING MONTH

SUBTOTAL

STAMPS AFFIXED DURING MONTH

(

) (

)

ON HAND AT END OF MONTH (UNAFFIXED)

AFFADAVIT:

I hereby swear under penalty of perjury that the foregoing return has been examined by me and that all information contained herein, including any accompanying schedules or statements is true and correct; and that this

constitutes a complete return for the month stated, pursuant to law. I also swear that the licensee is in compliance with the UNFAIR CIGARETTE SALE ACT, Chapter 26 of Title 6 of the Delaware Code.

_______________________________________________

_______________________

_________________________

SIGNATURE OF LICENSEE OR OFFICER THEREOF

TITLE

DATE

(Revised 07/30/09)