Form R-5629 - Consumer Excise Tax Return - 2002

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State of Louisiana
Social Security Number _________________________
R-5629 (8/02)
Department of Revenue
Taxpayer Services Division
Name _______________________________________
Excise Taxes Section
P.O. Box 3863
Address _____________________________________
Baton Rouge, LA 70821
(225) 219-7656
____________________________________________
(225) 219-2114 (TDD)
Consumer Excise Tax Return
Taxable Period ________________________________
Mail this return and payment to the address listed above.
DO NOT SEND CASH.
Consumer Excise Tax Notice to Taxpayers
Louisiana Alcoholic Beverage and Tobacco Tax laws levy an excise tax on all alcoholic beverages and tobacco products
sold or consumed in Louisiana. If you purchased alcohol or tobacco products for personal consumption from out-of-state
companies via means such as mail order, catalogs, the Internet, and were not properly charged Louisiana excise taxes, you
are required to file and pay the tax directly to the Department of Revenue. Use the form below to report any taxable
purchases made from companies that did not collect Louisiana excise taxes.
A
B
C
D
E
Schedule A -
Beer
Liquor
Wine More than
Wine between
Wine 14% &
Alcoholic Beverages
(Ounces)
(Liters)
24% Alcohol by
14% - 24%
Under Alcohol
Volume and
Alcohol by
(Liters)
Sparkling Wines
Volume
(Liters)
(Liters)
1. Total ounces or liters purchased
2. Amount subject to tax
(Divide Line 1 by 3968.)
3. Tax Rate
$10
$.66
$.42
$.06
$.03
4. Tax (See instructions.)
5. Parish / Municipality Tax
(Multiply Line 2 by $1.50.)
6. Amount Due (Add Lines 4 and 5.)
7. Total Alcoholic Beverages Tax
(Add Line 6 of Columns A through E.)
A
B
C
D
E
Schedule B -
Cigarettes
Cigars
Cigars
Smoking
Smokeless
Tobacco Products
(over $120 per
(up to $120
Tobacco
Tobacco
1,000 cigars)
per 1,000 cigars)
1. Cigarettes Sticks Purchased
2. Invoice Price
3. Tax Rate
$.012
$.20
$.08
$.33
$.20
4. Tax (Line 1 x 3 or Line 2 x 3)
5. Total Tobacco Products Tax
(Add Line 4 of Columns A through E.)
Total Taxes Due (Add Schedule A, Line 7 and Schedule B, Line 5.) ............................................................................ $ _____________
Mail this return to the post office box listed above.
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and
belief, it is true, correct, and complete.
_______________________________
______________
Signature
Date

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