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Wholesalers Quarterly Tobacco Shipment Report Form - South Dakota Department Of Revenue

EPORT DUE 10-20-2004

OUTH D

AKOTA DEPARTMENT OF REVENUE & REGULAT

ION

WHOLESALERS QUART

ERLY TOBACC

O SHIPMENT REPORT

eporting Period:

July 1, 2004 through September 31, 2004

outh Dakota License Number: ______________ Business Telephone Number _________________

usiness Name: ___________________________________________________________________

usiness Address: _________________________________________________________________

ailing Address (if different from above): ________________________________________________

ity, State, Zip: _____________________________________EIN/SSN Number: ________________

mail Address: _____________________________________

IST RYO INFORMATION:

Brand Name

NPM Name and

Supplier Name and

RYO Ounces

Address

you paid SD

D taxes were

Taxes On

already PAID

I swear under penalty of perjury that this report is, to the best of my knowledge and belief, true, correct and complete.

Name of Preparer (please type or print):_______________________________________Date: _____________________

ignature of Preparer: ______________________________________Telephone Number: ________________________

OVER FOR INSTRUCTIONS

Wholesalers Quarterly Tobacco Shipment Report Form - South Dakota Department Of Revenue