Form To-641 - Wholesale Tobacco Dealer Report Page 2
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1
2
3Vermont Department of Taxes
133 State Street
PO Box 547
Montpelier, VT 05601-0547
*156411200*
Phone: (802) 828-6839
VT Form
WHOLESALE TOBACCO DEALER REPORT
TO-641
* 1 5 6 4 1 1 2 0 0 *
This report is due on or before the 15th of each month to cover the preceding month.
Dealer’s Name
Federal ID Number
Address
Month
Year
City
State
ZIP Code
State License Number
-
E-mail address
Telephone Number
NEW SMOKELESS TOBACCO (NST)
1. Number of packages less than 1.2 ounces
in weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. ______________________
0.00
2. Multiply Line 1 by $3.08 . . . . . . . . . . . . . . . . . . 2. ______________________
3. Ounces of NST not reported on Line 1 . . . . . . . 3. ______________________
0.00
4. Multiply Line 3 by $2.57 . . . . . . . . . . . . . . . . . . 4. ______________________
0.00
5. NST Tax Due (Add Lines 2 and 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. ______________________
SNUFF
6. Total number of ounces sold during the month . 6. ______________________
0.00
7. Snuff Tax due (Multiply Line 6 by $2.57) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. ______________________
OTHER TOBACCO PRODUCTS (OTP)
8. Gross noncigar sales wholesale price exclusive
of tax (Multiply tax-included price by .521) . . . 8. ______________________
9. Exempt sales (Attach explanation of exempt
sales.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. ______________________
0.00
10. Net taxable sales (Subtract Line 9 from Line 8) 10. ______________________
11. OTP Tax due excluding cigars
0.00
(Multiply Line 10 by 92%) . . . . . . . . . . . . . . . .11. ______________________
12. Tax due on cigars
0.00
(from Cigar Schedule B, Line 29) . . . . . . . . . . 12. ______________________
0.00
13. Total OTP Tax Due (Add Line 11 plus Line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. ______________________
TOTAL TAX DUE
0.00
14. Tax due on NST, Snuff, and OTP (Add Lines 5, 7, and 13) . . . . . . . . . . . . . . . . . . . 14. ______________________
15. Discount if paid by the 15th (Multiply Line 14 by 2%) . . . . . . . . . . . . . . . . . . . . . . 15. ______________________
0.00
16. TOTAL TAX DUE (Subtract Line 15 from Line 14) . . . . . . . . . . . . . . . . . . . . . . . . 16. ______________________
Make checks payable to Vermont Department of Taxes
SIGNATURE
I hereby swear, under pains and penalty of perjury, that this information is true and correct to the best of my knowledge.
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Here
Signature of Licensee
Printed Name
Title
Date
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Form TO-641
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(Rev. 06/15)
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