Form Dr 1285 - Licensed Distributor Reporting Form For Cigarettes Sales Of Non-Participating Manufacturer Brands - 2010

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DR 1285 (11/18/10)
COLORADO DEPARTMENT OF REVENUE
EXCISE TAX ACCOUNTING SECTION
1375 SHERMAN STREET
LICENSED DISTRIBUTOR REPORTING FORM FOR CIGARETTES
18
76
DENVER, CO 80261
(303) 205-8211 EXT 6848
SALES OF NON-PARTICIPATING MANUFACTURER BRANDS
FAX (303) 205-8204
Identifying Information
Due Date: 20th of Each Month
Reporting Month and Year
Business Name
Business Address
Business Registration Number
Contact Person
Telephone Number
FAX Number
Email Address (required)
Tax Paid Sales and Tax Exempt Sales
Provide the following information regarding:
—
•
Cigarettes manufactured by a Non-Participating Manufacturer that bear a Colorado cigarette tax stamp
•
Tax paid Non-Participating Manufacturer Roll-Your-Own Tobacco sold in Colorado
A
B
C
D
E
F
G
Brand Name
Number of
Number of ounces
Number of sticks
Non-participating
Name and address
If Product is Tax
cigarettes (sticks)
(oz.) of roll-your-own
converted from
manufacturer name
from which each
Exempt, Check
sold within
(RYO)
ounces of RYO
and address
brand was
Box Below
Colorado
(ounces ÷ .09)
purchased
I certify that the above-stated information is true and correct.
Signature
Date
Print Name and Title
Page ____of____
Failure to file this report as required may result in the revocation of your cigarette and/or tobacco products license(s) for a period of two years.
Distributor is responsible to notify the Department of any changes to address, telephone number, FAX number or E-mail address.
Under Regulation 39-28-303(2)(c), an email address must be provided to the department for the purposes of the distributor receiving notice of any addition or removal from the
Colorado Certified Brands Directory (CBD). Any subsequent change of the email address shall be submitted to the department by email or in writing within five (5) business days
after the change of the email address. You can notify the department at the address or the fax number at the top of this form or at mastersettlement@spike.dor.state.co.us

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