Form Tob: T-Whsle - Monthly Report By Resident Wholesale Dealers In Cigarette Products - 2005 Page 2

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PART II – Cigarette Products Actually Purchased And Received During The Month
CIGARETTES ONLY
INVOICE
RECEIPT
FROM WHOM PURCHASED AND RECEIVED
(a)
(b)
DATE
NUMBER
DATE
(NAME AND ADDRESS)
NUMBER OF
TAX VALUE
CIGARETTES
(Col. a x $0.02125)
TOTALS (Enter here and also Part I, line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
If additional space is needed, attach additional sheets with identical headings. A computer printout with identical headings is
acceptable; however, totals should be entered on this page.

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