Form Sd Eform - 1789 V7 - Distributors Quarterly Tobacco Shipment Report - South Dakota Department Of Revenue & Regulation

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SD EForm -
1789
V7
Complete and use the button at the end to print for mailing.
HELP
SOUTH DAKOTA DEPARTMENT OF REVENUE & REGULATION
DISTRIBUTORS QUARTERLY TOBACCO SHIPMENT REPORT
Reporting Period:
___January 1, through March 31, ______
___April 1, through June 30, ______
(Check one)
Due April 20
Due July 20
___July 1, through September 30, ______
___October 1, through December 31, ______
Due October 20
Due January 20
South Dakota License Number: _____________________Business Telephone Number __________________________
Business Name: ___________________________________________________________________________________
Business Address: _________________________________________________________________________________
Mailing Address (if different from above): ________________________________________________________________
City, State, Zip: ____________________________________________EIN/SSN Number: _________________________
Email Address: ____________________________________________________________________________________
LIST CIGARETTE INFORMATION:
A
B
C
D
Brand Name
Number of
NPM Name and Address
Supplier Name and Address
Cigarettes Sold
LIST RYO INFORMATION:
E
F
G
H
I
J
Brand Name
NPM Name and
Supplier Name and
RYO Ounces
RYO Ounces
Wholesaler Name
Address
Address
you paid SD
Shipped to
and Address for
Taxes On
Wholesaler
RYO, taxes not 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: _____________________
Signature of Preparer: ______________________________________Telephone Number: ________________________
ATTACH DOCUMENTATION. SEE INSTRUCTIONS.
CLEAR FORM
PRINT FOR MAILING

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