Form Ct-111 - Cigarette Warehouse Report - 2010
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1
2CT-111
CIGARETTE WAREHOUSE
Form
REPORT
Tax Account Number
Wisconsin
Department of Revenue
FEIN / SSN
Month Ending (MM DD YYYY)
Use BLACK INK Only
Cancel my permit effective
Legal Name
Business Name (DBA)
(MM DD YYYY)
Check if address, name, or entity
Permit/Business Address
change
Check if this is an amended return
City
State
Zip Code
Check if correspondence is included
Print numbers like this
Not like this
NO COMMAS
REPORT OF UNSTAMPED CIGARETTES IN WISCONSIN WAREHOUSE
Total Single Cigarettes
1
Name of Manufacturer
TOTAL
Beginning Inventory
2
(Line 7 of the preceding month)
Receivals
3
TOTAL
4
(Add Lines 2 and 3)
5
Shipments
Balance to Be Accounted for
6
(Subtract Line 5 from Line 4)
7
End of Month Physical Inventory
Inventory Discrepancies
Overage - When Line 7 exceeds Line 6 use
8
negative sign in front of the amount on Line 8.
Shortage - When Line 6 exceeds Line 7.
DECLARATION: I declare under penalties of law that I have examined this return and all attachments and, to the best of my knowledge
and belief, it is true, correct, and complete.
Preparer’s Phone Number
Signature of Permittee (or authorized agent)
Preparer’s Name (please print or type)
Date
(
)
Mail your return to:
Questions or need more forms?
Call (608) 266-8970 Fax (608) 261-7049
Wisconsin Department of Revenue
Mail Stop 5-107
E-mail: excise@revenue.wi.gov
PO Box 8900
Website:
Madison WI 53708-8900
CT-111i (N. 7-09)
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