Form 69-114 - Cigars And Tobacco Products Tax Credit Worksheet
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269-114
(Rev.9-09/5)
PRINT FORM
CLEAR FIELDS
b.
CIGARS AND TOBACCO PRODUCTS TAX
CREDIT WORKSHEET
Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in accordance
with Ch. 552, Government Code. To request information for review or to request error correction, contact us at the phone number listed on this form.
a) Taxpayer name
SEE INSTRUCTIONS ON BACK
FOR APPROPRIATE
c) Taxpayer number
TAX RATES.
For assistance, call
d) Location (city)
(800) 862-2260 or (512) 463-3731.
e)
f)
g)
h)
i)
j)
CIGAR QUANTITY
CREDIT
CREDIT
MANUFACTURER
COMPTROLLER
CLASS
OR TOBACCO
TAX VALUE
DATE
NUMBER
NAME
USE
PRODUCT TOTALS
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
ea.
oz.
k)
TOTAL CREDITS
STATE OF _____________________________
COUNTY OF ___________________________
Personally appeared before me _______________________________________________________________________ of
__________________________________________________________ who being duly sworn, says that he/she personally
returned the above described tobacco products to the manufacturers described. Affidavit and credit memos attached.
Sworn and subscribed to before me this ______ day of __________________________ 20 ________ .
Notary Public ____________________________________
( NOTARY SEAL )
County _________________________________________
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