Licensed Distributor Report Form

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Tennessee Department of Revenue

FOR OFFICE USE ONLY

Please complete this form each month in full and mail the signed

original to:

Licensed Distributor Report

TN DEPARTMENT OF REVENUE

(This Report Should Contain All Brands of Cigarettes and RYO

ANDREW JACKSON STATE OFFICE BUILDING

P.O. BOX 190590

on which Tennessee tax was paid, by stamp or otherwise).

NASHVILLE, TN 37219

Reporting Period: Month ______________________________ Year ____________

AMENDED REPORT

Tobacco Wholesale Account No. ___________________________________________________________

- See additional requirements in instructions.

By checking this box I hereby certify the packaging of brands has not changed since prior reporting period ( IF

Business Name: __________________________________________________________________________

UNCHECKED, new packaging must be attached ).

**** IF YOU ARE NOT REPORTING AT THIS TIME,

Address: ________________________________________________________________________________

YOU MUST CHECK THE BOX BELOW THAT APPLIES.

All products pre-stamped or tobacco product tax pre-

No TN Sales Activity

City, State, Zip: __________________________________________________________________________

paid this reporting period (NO TN stamps affixed this

reporting period).

Big Cigars ONLY

Email: ___________________________________________________________________________________

** IF ANY UNSTAMPED OR STAMPED PRODUCTS WERE SOLD TO ANOTHER LICENSED DISTRIBUTOR, ALSO ATTACH W2W FORM TO THIS REPORT. **

Column 1

Column 2

Column 3

Column 4

Column 5

Column 6

No. of Cigarettes or Little Cigars or Oz. of

Brand Family

Roll-Your-Own Products on which you

(One entry for each Brand family. Do NOT

Name and Address of the Entity/Person from

Name and Address of the First Importer

affixed the tax stamp or otherwise paid

Type of Product:

the TN tax due.

list out Lights, Kings, etc.)

Whom Each Brand Family Was Purchased

(Foreign Manufactured Brand Families Only)

Manufacturer (Name & Address)

C, LC, B or RYO

*** MORE REPORTING SPACE AVAILABLE ON SUPPLEMENTAL PAGE ***

PLEASE READ BEFORE SIGNING: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing report is true and correct, and that the report only contains cigarettes on

which I have placed a tax stamp or, in the case of RYO, RYO on which I have paid the tax due. I declare that I am authorized to certify, on behalf of the reporting company named above, that all of the information

contained in this form is complete and accurate. _______ (Initials of Authorized Signator)

______________________________________________________________

Signature of Company Officer:

Date: ____________________________

______________________________________________________________

Print Company Officer Name:

Phone No.

__________________________________ Fax No. ____________________________

______________________________________________________________

Page ____ of _____

Print Company Officer Title:

RV-F1303801 (Rev. 8/1/09)