Licensed Distributor Report Form Page 3

Download a blank fillable Licensed Distributor Report Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Licensed Distributor Report Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Tennessee Department of Revenue

FOR OFFICE USE ONLY

Monthly Report of All Cigarettes, Little Cigars &/or Roll-Your-Own

Form W2W

Sold to Other Licensed Wholesaler/Distributors

Reporting Period: Month ______________________________ Year ____________

Business Name

Tobacco Wholesale Account No.

Business Address

Name & Title of Person Authorizing Report

City

State

Zip Code

Email Address

Phone #

Fax #

Columns:

1. Date of shipment or transfer to purchasing wholesaler/distributor.

5. Indicate what type of product was sold--cigarettes (C ), roll your own (RYO), bidis (B), or little cigars (LC).

2. Indicate how shipped: DT (Distributors Truck); CC (Common Carrier); PP (Parcel Post);

6. Indicate "S" for stamped and "U" for unstamped as it pertains to each brand listed.

CT (Customer Truck)

7. Complete name and address of company or person to whom cigarettes were sold.

3. Invoice Number of product shipped to another wholesaler.

8. Number of sticks (or ounces, if RYO) sold to Purchasing Wholesaler/Distributor.

9. When using additional pages, please number accordingly in the lower right hand corner of this form.

4. Enter brands sold. Use a separate line for each brand family. Use additional sheets if necessary.

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Type of

# of Sticks &/or Oz. Sold to

Product: C,

Stamped or

Purchasing

Name and complete address of Purchasing Wholesaler, whether Purchasing Wholesaler is located in

Date

How Shipped

Brands Sold

RYO, B or LC

Unstamped

Wholesaler/Distributor

Invoice Number

Tennessee or Out‐of‐State.

I certify under penalty of perjury that the above-stated information is true and correct. 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)

Mail the original form(s) to:

Signature __________________________________________Date _____________

1) TN Department of Revenue, Andrew Jackson Bldg., P.O. Box 190590, Nashville, TN 37219

W2W Report Form

Page ____ of _____