Iowa Cigarette Tax Report
Iowa Department of Revenue
In-State Distributors
FOR OFFICE USE ONLY
RETURN FOR MONTH OF _________________ YEAR __________
Postmark Date:
Audit Period: ___________________
DUE DATE: On or before the 10th day of the month following the
month for which the report is made.
MAIL THIS FORM TO:
PERMIT NO: ___________________________________
Iowa Department of Revenue
PO Box 10456
NAME: ______________________________________
Des Moines IA 50306-0456
ADDRESS: ______________________________________
OR FAX IT TO: 515-281-3756
FOR ASSISTANCE, CALL: 515-281-8023
______________________________________
Only approved brands of cigarettes may be sold
______________________________________
in Iowa. Any product not on the list is contraband.
Go to /business/CigTobIndex.html
SECTION I. IOWA REVENUE PURCHASED FOR THE MONTH
Cigarette reports and
Total Order
all supporting
Cigarette Stamps
in Dollars and Cents with No Discount
documentation are
Date
Packs of 20
Packs of 25
Packs of 20
Packs of 25
required to be
maintained for five
years.
TOTALS:
To Section II line 2 under Iowa
SECTION II. REVENUE STAMPS SUMMARY
Iowa
Iowa
Totals
Totals
TOTAL STAMPS
(out of state)
(out of state)
FOR PACKS OF
20’s
25’s
20’s
25’s
20’s
25’s
1. Beginning inventory
(prior month’s ending inventory unaffixed stamps)
1.
2. Add purchases this month (from Section I)
2.
3. Subtotal
3.
4. Less ending inventory (this month’s unaffixed stamps)
4.
5. Balance (revenue stamps used this month)
(A)
5.
SECTION III. CIGARETTE PACKS SUMMARY
Packs of 20’s
and Little Cigars
Packs of 25’s
Total
1. Beginning inventory (prior month’s unstamped packs)
1.
NOTE:
2. Add purchases this month
2.
If (A) totals do
3. Subtotal: Add lines 1 and 2
3.
NOT equal (B)
4. Less ending inventory this month (unstamped packs)
totals,
4.
attach an
5. Subtotal: Line 3 less line 4
5.
explanation.
6. Less little cigars sold out of state this month
6.
7. Balance: Line 5 less line 6
(B)
7.
8. Stamped packs returned to manufacturer
8.
I declare that I have examined this report and to the best of my knowledge and belief, it is a true, correct and complete report.
Signature of Permitee or Officer: _____________________________________ Telephone Number: ________________________
Title of Officer: ___________________________________________________ Date: _______________________
70-017a (06/11/10)