Licensed Distributor Report Form Page 2

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Tennessee Department of Revenue

FOR OFFICE USE ONLY

Account No.____________________________

Brand Specific Licensed Distributor Report

Name:_________________________________

With Tennessee Tax Paid On Sales by All Manufacturers

(INSTRUCTIONS ON REVERSE SIDE)

Reporting Period: Month ______________________________ Year ____________

Column 1

Column 2

Column 3

Column 4

Column 5

Column 6

No. of Cigarettes or Little Cigars or Oz. of

Roll-Your-Own Products or bidis on which

Brand Family

Type of Product:

you affixed the tax stamp or otherwise

(One entry for each Brand family. Do NOT

Name and Address of the Entity/Person from

Name and Address of the First Importer

C, LC, or B or

paid the TN tax due.

list out Lights, Kings, etc.)

Whom Each Brand Family Was Purchased

(Foreign Manufactured Brand Families Only)

Manufacturer (Name & Address)

RYO

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:

Page ____ of _____

SUPPLEMENTAL PAGE

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