Form Tobacco Products Tax - Resident Distributor - 2003

Department of Revenue Services

Schedule C-1

State of Connecticut

Excise/Public Services Taxes Subdivision

Tobacco Products Tax - Resident Distributor

25 Sigourney Street

Hartford CT 06106

Record of snuff tobacco products exported out of Connecticut or sold to the federal government

(Rev. 05/03)

Enter the total of Schedule C-1 on Line 2 of Schedule A-3, Tobacco Products Tax - Resident Distributor - Snuff Tobacco Products Activity Report . Attach Schedule C-1 to Form OP-300, Tobacco Products Tax Return.

Name ___________________________________________________

Period Ending __________________

CT Tax Registration Number __________________________

State of Destination __________________________________________________________________________________________________________________________________

Invoice

Invoice

Tax

Weight each

Total Weight

Customer Name

State

Quantity

(Col. 10 x 0.40)

Date

Number

City

ZIP Code

Brand Name

(in ounces)

(Col. 8 x 9)

Column 3

Column 4

Column 5

Column 6

Column 7

Column 8

Column 9

Column 10

Column 11

Column 1

Column 2

Report this amount on Line 2 of Schedule A-3

Total