Form Au-686 - Roll-Your-Own Cigarette Tobacco Product Declaration - Connecticut Department Of Revenue Services

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STATE OF CONNECTICUT
Form AU-686
DEPARTMENT OF REVENUE SERVICES
Excise/Public Services Subdivision
25 Sigourney Street
Roll-Your-Own Cigarette
Hartford CT 06106
Tobacco Product Declaration
(New 09/01)
Tobacco Products Distributor’s Name
Date Received (For Department Use Only)
Contact Person
Telephone Number
Connecticut Tax Registration Number
(
)
Mailing Address
Number and Street
City, Town or Post Office
State
Zip Code
Physical Location
Number and Street
City, Town or Post Office
State
Zip Code
1. Since July 1, 2000, I have not purchased untaxed roll-your-own cigarette tobacco products. I understand that “untaxed roll-
your-own cigarette tobacco products” means any roll-your-own cigarette tobacco products on which Connecticut tobacco
products tax has not been paid.
2. I understand that by signing this declaration I will not be required to file Schedule E, Roll-Your-Own Tobacco Products
Purchased, Acquired or Shipped Into Connecticut During the Month , with my monthly Form OP-300, Tobacco Products Tax
Return.
3. I also understand that, if I purchase untaxed roll-your-own cigarette tobacco products, I will be required to file Schedule E
with my monthly Tobacco Products Tax Return.
Declaration: I declare under the penalty of law that I have examined this declaration (including any accompanying schedules and
statements) and, to the best of my knowledge and belief, it is true, complete, and correct. I understand that the penalty for willfully
delivering a false return to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The
declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Signature:
Date
Print Name:
Title:

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