Form 70-017a - Iowa In-State Distributors Cigarette Tax Report Page 4
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4SECTION IV. DISTRIBUTOR’S RECORD OF CIGARETTES RECEIVED
Manufacturer: ___________________________________
PHILLIP MORRIS
R.J. REYNOLDS
Packs of 20’s
Packs of
Packs of 20’s
Packs of
Packs of 20’s
Packs of
Date
Invoice No.
& Little Cigars
25’s
Date
Invoice No.
& Little Cigars
25’s
Date
Invoice No.
& Little Cigars
25’s
TOTALS
Manufacturer: ___________________________________
Packs of 20’s
Packs of
Date
Invoice No.
& Little Cigars
25’s
TOTALS
Manufacturer: ___________________________________
Packs of 20’s
Packs of
Date
Invoice No.
& Little Cigars
25’s
TOTALS
TOTALS
TOTALS
Iowa 70-017d (5/19/04)
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