Cigarette Report of Purchases from
Nonparticipating Manufacturers
State of Iowa
Due January 31, 2001
This report is for the period of January 1, 2000 through December 31, 2000.
Step 1:
Distributor information
Step 2:
Nonparticipating manufacturer information
Number of individual
cigarettes sold
bearing IA tax stamps
1 ___________________________
____________________________________
__________
_____________
2 ___________________________
____________________________________
__________
_____________
3 ___________________________
____________________________________
__________
_____________
4 ___________________________
____________________________________
__________
_____________
5 ___________________________
____________________________________
__________
_____________
6 ___________________________
____________________________________
__________
_____________
7 ___________________________
____________________________________
__________
_____________
8 ___________________________
____________________________________
__________
_____________
Where do I send my completed report?
Distributor Signature: ________________________ Date: _________
IOWA