NEVADA DEPARTMENT OF TAXATION
1550 East College Parkway, Suite #115
Carson City, NV 89706
(775) 687-6483
Licensed Distributor Reporting Form for Cigarettes Sales of Non-Participating Manufacturer Brands
READ INSTRUCTIONS ON THE REVERSE SIDE OF THIS REPORT BEFORE PREPARING
Cigarette Wholesaler License No. __________________________
For the Month of
Wholesaler ______________________________
A
B
C
D
E
No. of Cigarettes
Non-Participating Manufacturer Name and
Name and Address of the Person(s) From Whom Each
Name and Address of First Importer of Foreign
Brand Name
Sold Within State
Address (if known)
Brand Was Purchased
Manufactured Brands (if Known)
8/1/2001
CT 03