Form To-641 - Wholesale Tobacco Dealer Report Page 3
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1
2
3Dealer’s Name
Federal ID Number
Reporting Period (MMYYYY)
Schedule A
Invoice Date
Invoice Number
To Whom Sold or Shipped
Address
“Wholesale Price”
Cigar Schedule B
CATEGORY I. Tax on cigars with wholesale price of $2.17 or less
17. Wholesale value of cigars
(Multiply tax included price by .521) . . . . . . . 17. _______________________
18. Less: Exempt Sales (Shipped out of state) . . . 18. _______________________
19. Amount subject to tax
0.00
(Line 17 minus Line 18) . . . . . . . . . . . . . . . . . 19. _______________________
0.00
20. Tax Due (Line 19 x 92%). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. ______________________
CATEGORY II. Tax on cigars with wholesale price of $2.18 - $9.99
21. Number of cigars sold . . . . . . . . . . . . . . . . . . . 21. _______________________
22. Less: Exempt Sales (Shipped out of state) . . . 22. _______________________
23. Total cigars subject to tax
0
(Line 21 minus Line 22) . . . . . . . . . . . . . . . . . 23. _______________________
0.00
24. Tax Due (Line 23 x $2.00) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24. ______________________
CATEGORY III. Tax on cigars with wholesale price of $10.00 or greater
25. Number of cigars sold . . . . . . . . . . . . . . . . . . . 25. _______________________
26. Less: Exempt Sales (Shipped out of state) . . . 26. _______________________
27. Total cigars subject to tax
0
(Line 25 minus Line 26) . . . . . . . . . . . . . . . . . 27. _______________________
0.00
28. Tax Due (Line 27 x $4.00) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28. ______________________
0.00
29. Total Tax Due (Add Lines 20, 24, and 28) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29. ______________________
Transfer this amount to Form TO-641, Line 12 and attach this schedule to the report.
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Important Printing Instructions
Form TO-641
(Rev. 06/15)
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