Form Ct-19 - Cigarette Brand Family Quarterly Report - 2003
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1Indiana Department of Revenue
Report
Report
CT-19
P.O. Box 901
Period
Due
7/03
Indianapolis, IN 46206-0901
7-1 to 9-30
10-20
Cigarette Brand Family
10-1 to 12-31
1-20
Quarterly Report
1-1 to 3-31
4-20
Indiana Code 24-3-5.4-17
4-1 to 6-30
7-20
Distributor Name
Distributor License Number
Report Period
From:
mm/yyyy
To:
mm/yyyy
Instructions: Complete the Distributor Name, License Number and the period you are reporting. List the Brand Family, Number of
Cigarettes, Roll-Your-Own Tobacco, and the Name and Address of Distributor from whom cigarettes/tobacco were purchased. “Number
of Cigarettes” should be cigarette sticks and not packs or cartons. Roll-your-own tobacco should be listed in units. The taxpayer or Agent
must complete their name, title and telephone number, and date the form is being completed.
Report cigarettes when stamped and Roll-Your-Own when excise tax was paid during the immediate preceding 3 months.
Note: The term “roll-your-own” tobacco is any tobacco which because of its apprearance, type, packaging, or labeling, is suitable for use
and likely to be offered to, or purchased by consumers as tobacco for making cigarettes. Nine-hundredths (0.09) of an ounce of “roll-your-
own” tobacco constitutes one (1) individual cigarette or unit.
Roll-Your-Own
Number of
Brand
Purchased from
Tobacco
Cigarettes
Family
Name and Address
(units)
(sticks)
Attach additional sheets if necessary.
Forms may be obtained from
I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and
statements is true, correct, and complete to the best of my knowledge and belief.
Signature of Taxpayer or Agent
Title
Telephone Number
Date
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