Form 801-R - Tobacco Products Monthly Tax Return Page 2
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1
2
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5801
)
for
TOB-SCHEDULE A (
Form
R
S
A
CHEDULE
TIN / SSN : # ______________________
SMOKING TOBACCO, SNUFF, CHEWING TOBACCO, ETC.
Page ___ of ___
Taxpayer Name
Reporting Month
Date
Name of Supplier
Invoice Number
Quantity (Ounces)
Total Ounces Purchased :
Use Additional Sheets If Necessary.
Tax Due (Total Ounces * $.113) :
[Enter Here & on Line 1 of Form 801R]
Note: Fractions of ounces of 50% or greater are to be treated as full ounces
TOB - Form 801R
ONTC
Schedule A
Revised: 8/12/2010
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