Form Dr 1285 - Licensed Distributor Reporting Form For Cigarette Sales Of Non-Participating Manufacturer Brands - 2003

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DR 1285 (6/03)
LICENSED DISTRIBUTOR REPORTING FORM FOR CIGARETTE
Colorado Department of Revenue
SALES OF NON-PARTICIPATING MANUFACTURER BRANDS
Business Tax Accounting Section
1375 Sherman Street, Room 208
Denver, CO 80261
Provide the following information regarding:
(303) 205-8211, Ext. 6860
FAX: (303) 866-3211
Cigarettes manufactured by a Non-participating Manufacturer that bear a Colorado cigarette tax stamp
Roll-your-own tobacco manufactured by a Non-participating Manufacturer sold in Colorado
TH
DUE DATE: 20
DAY OF EACH MONTH FOLLOWING
SEE REVERSE FOR INSTRUCTIONS
THE CLOSE OF THE REPORTING MONTH
Reporting Month/Year
Business Name
Business Address
Telephone Number, Email address and Fax Number
Business Registration Number
Contact Person
C
D
E
F
A
B
OUNCES
BRAND NAME
NON-PARTICIPATING
NAME AND ADDRESS OF THE
NAME AND ADDRESS OF THE
NUMBER OF
CONVERTED TO
MANUFACTURER
PERSON(S) FROM WHOM EACH
FIRST IMPORTER OF
CIGARETTES
STICKS OF
NAME AND ADDRESS
BRAND WAS PURCHASED
FOREIGN MANUFACTURED
(STICKS)
ROLL-YOUR-
BRANDS
SOLD WITHIN
OWN TOBACCO
COLORADO
SOLD WITHIN
COLORADO
I
-
CERTIFY THAT THE ABOVE
STATED INFORMATION IS TRUE AND CORRECT
S
__________________________________________
________________________
IGNATURE
DATE
P
N
& T
__________________________________
P
_____
_______
RINT
AME
ITLE
AGE
OF
F
/
(
)
.
AILURE TO FILE THIS REPORT AS REQUIRED MAY RESULT IN THE REVOCATION OF YOUR CIGARETTE AND
OR TOBACCO PRODUCTS LICENSE
S
FOR A PERIOD OF TWO YEARS

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