Form 801-R - Tobacco Products Monthly Tax Return Page 3
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1
2
3
4
5801
)
for
TOB-SCHEDULE B (
Form
R
S
B
CHEDULE
TIN / SSN : # ____________________
C
P
A
T
T
AVENDISH,
LUG,
ND
WIST
OBACCO
Page ___ of ___
Taxpayer Name
Reporting Month
Date
Name of Supplier
Invoice Number
Quantity (Number of Ounces)
Total Ounces Purchased :
Tax Due (Total Ounces * $0.028) :
[Enter Here & on Line 2 of Form 801R]
Note: Fractional part of ounces are to be treated as full ounces
TOB - Form 801R
ONTC
Schedule B
Revised: 8/12/2010
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