Form Tc-557 - Utah State Cigarette And Tobacco Pact Act Monthly Report
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Utah State Tax Commission
210 N 1950 W • Salt Lake City, UT 84134 •
TC-557
Utah State Cigarette and Tobacco
Rev. 4/11
PACT Act Monthly Report
1. Reporting Entity
2. Reporting Period
Business name
Account number
Tax Period:
Address
Utah Tobacco License number
_______ _ ________
City
State
ZIP Code
Country
Phone
Email address
Web address
Check box if AMENDED
Contact person
Title
3. Sales into Utah
A. Invoice
B. Purchaser Info
C. Product Type (mark one)
D. Brand
E. Quantity Sold
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Invoice date
Name
FEIN
Cigarettes
Moist snuff
(sticks)
(ounces)
Invoice number
Address
UT Tobacco Lic. no.
Little cigars
RYO
(sticks)
(ounces)
Use as many copies of the next page as you need to report additional sales
Under penalty of falsification, I declare that, to the best of my knowledge, all the information in this Request and any
attached documentation is true and complete.
_______ ____________________ __
__ ____________ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Authorized Signature
Title
Date
Telephone
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