Form Rpd 41188 - Licensed Distributor Reporting Form For Cigarette Sales Of Non-Participating Manufacturer Brands
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2RPD 41188
State of New Mexico - Taxation and Revenue Department
Rev. 06/2004
LICENSED DISTRIBUTOR REPORTING FORM FOR CIGARETTE SALES OF
NON-PARTICIPATING MANUFACTURER BRANDS
(Instructions on reverse side)
Reporting Month/Year: _______________________
page ___1__ of ______
Please provide the following information about cigarettes (including “roll-your-own”) made by Non-Participating Manufacturers (NPM) and stamped for sale within this state.
Business Name: ____________________________________________ Address: ___________________________________________________
FEIN: ___________________CRS:_________________ Contact Person: _________________________________ Phone: __________________
Licensed distributors must submit this form monthly on or before the 25th day following the close of the reporting month.
If you have not sold any tobacco products from non-participating manufacturers, please check this box.
No. of
Ounces of roll-your-
Name and address of the person(s)
Name and address of the first
Brand Name
Non-participating
(column a)
cigarettes sold
own tobacco sold
from whom each brand
importer of foreign manufactured
manufacturer name and
was purchased
within state
within state
address
brands (if known)
(column b)
(column c)
(column e)
(column f)
(column d)
Under penalty of perjury I declare that I have examined this return, and the information reported on this form and any attached supplements is true,
correct and complete.
_________________________________________________________________________
_____________________________
Signature
Date
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