Form Dp-197 - Wholesaler Tobacco Stamp Inventory - Department Of Revenue Administration - 2008
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2FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
DP-197
WHOLESALER TOBACCO STAMP INVENTORY
THIS FORM IS TO BE COMPLETED AS OF THE
CLOSE OF BUSINESS ON JUNE 30, 2008
NAME OF TAXPAYER
LICENSE NUMBER
TRADE NAME
NUMBER & STREET ADDRESS
ADDRESS (continued)
CITY/TOWN, STATE & ZIP CODE
SEE LINE-BY-LINE INSTRUCTIONS
NUMBER OF STAMPS
Enter the number of 20 Pack Cigarette B Tax Stamps affi xed to Packs.
1
2
Enter the number of 20 Pack Cigarette B Tax Stamps NOT affi xed to Packs.
3
Enter the number of 20 Pack Cigarette B Tax Stamps affi xed to Packs in Transit.
4
Total Number of B Stamps (Sum of Lines 1, 2 and 3).
5
Enter the number of 25 Pack Cigarette A Tax Stamps affi xed to Packs.
6
Enter the number of 25 Pack Cigarette A Tax Stamps NOT affi xed to Packs.
7
Enter the number of 25 Pack Cigarette A Tax Stamps affi xed to Packs in Transit.
8
Total Number of A Stamps (Sum of Lines 5, 6 and 7).
9
Under penalties of perjury, I declare that I have examined this return, and to the best of my belief it is true, correct and complete. If prepared
by a person other than the taxpayer, this declaration is based on all information of which the preparer has knowledge.
X
SIGNATURE OF PAID
PREPARER (IN INK)
OTHER THAN TAXPAYER
DATE
SIGNATURE (IN INK)
DATE
PRINT SIGNATORY NAME
PRINT PAID PREPARER NAME
TITLE
PREPARER'S IDENTIFICATION NUMBER
PHONE NUMBER AND E-MAIL ADDRESS
PREPARER'S STREET ADDRESS/PO BOX
CITY/TOWN, STATE and ZIP CODE
NH DRA
MAIL
PO BOX 457
TO:
CONCORD NH 03302-0457
FOR DRA USE ONLY
DP-197
Rev. 6/2008
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