Form 73a422 - Monthly Report Of Other Tobacco Products And Snuff (Page 2 of 2) in pdf

Form 73a422 - Monthly Report Of Other Tobacco Products And Snuff Page 2

73A422 (4-09)

PART III—MONTHLY REPORT OF NONPARTICIPATING MANUFACTURER

Page 2

ROLL YOUR OWN TOBACCO SOLD IN KENTUCKY

Wholesaler

City

License /Account Number

For Month/Year

INSTRUCTIONS: KRS 131.600(10), effective June 30, 2000, directs the Kentucky Department of Revenue to ascertain the number of units (individual cigarettes) sold in the state

each year by nonparticipating manufacturers (manufacturers and importers of cigarettes who did not sign the Master Settlement Agreement (MSA) entered into on November 23,

1998, with this state). Effective April 25, 2006, roll your own tobacco is to be reported for MSA purposes.

List the nonparticipating manufacturer for each brand that was sold in Kentucky during the month on which the other tobacco products tax was paid. If the roll your own tobacco

was not purchased directly from the manufacturer, that information may be obtained from the carton or packaging. If the roll your own tobacco was received from another wholesaler

who has already paid the other tobacco products tax, do not list on this report. If you do not sell any roll your own tobacco during the month from a nonparticipating manufacturer,

enter “NONE” in the boxes. All boxes must be completed.

A copy of all invoices covering these shipments to you should be attached to this report.

Nonparticipating Manufacturer Has a

Name and Address of Seller

Ounces of Roll Your

Qualiﬁ ed Escrow Account

Brand

Nonparticipating

From Whom Brand Was Purchased

Own Tobacco Sold

(Indicate if Known)

Name

Manufacturer’s Name and Address

(If Different from Original Manufacturer)

in Kentucky

Yes

➤ IMPORTANT:

I agree to allow the Kentucky Department of Revenue or the Attorney General to release to the manufacturer information which I have provided on part III

of Revenue Form 73A422, Monthly Report of Other Tobacco Products and Snuff. I understand that this information might ultimately become part of an

ofﬁ cial court record if an enforcement action is taken against that manufacturer.