Form 1075 - Non-Resident Wholesale Dealer'S Monthly Report Of Cigarette And Cigarette Tax Stamps Page 5

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W
8
P
SCHEDULE NPM
MONTH OF __________________________, 20___
CIGARETTE SALES OF
NON-PARTICIPATING MANUFACTURER BRANDS
BUSINESS NAME & ADDRESS: _________________________________________
EMPLOYER IDENTIFICATION NUMBER: _____________________________________
CONTACT PERSON: ___________________________________________________
TELEPHONE NUMBER: ____________________________________________________
NUMBER OF CIGARETTE
NAME & ADDRESS OF THE
NAME & ADDRESS OF THE
OUNCES
NON-PARTICIPATING
PACKS SOLD
BRAND NAME
PERSON(S) FROM WHOM EACH
FIRST IMPORTER OF FOREIGN
OF RYO
MANUFACTURER NAME & ADDRESS
BRAND WAS PURCHASED
MANUFACTURED BRANDS
25'S
20'S
I certify that the above stated information is true and correct.
Signature
Date
(Revised 07/2009)

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