Form 1074 - Resident Wholesale Dealer'S Monthly Report Of Cigarette And Cigarette Tax Stamps

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FORM 1074

STATE OF DELAWARE

Print Form

DIVISION OF REVENUE

RESIDENT WHOLESALE DEALER'S

MONTHLY REPORT OF

FOR OFFICE USE ONLY REVENUE CODE: 0035-02

CIGARETTE AND CIGARETTE TAX STAMPS

NAME:

EMPLOYER IDENTIFICATION NUMBER:

ADDRESS:

REPORT FOR MONTH OF:

CITY:

TELEPHONE NUMBER:

STATE:

ZIP CODE:

FAX NUMBER:

NO NON-PARTICIPATING MANUFACTURER PRODUCTS SOLD INTO DELAWARE: [ ] NO

[ ] IF YES, COMPLETE SCHEDULE NPM

PACKAGES OF CIGARETTES

SCHEDULE

CIGARETTE ACCOUNT

20'S

25'S

TOTAL

ON HAND AT BEGINNING OF MONTH (STAMPED)

ON HAND AT BEGINNING OF MONTH (UNSTAMPED)

1074-A

RECEIVED FROM MANUFACTURERS (STAMPED)

1074-A

RECEIVED FROM MANUFACTURERS (UNSTAMPED)

1074-B

RECEIVED FROM OTHER THAN MNFR (STAMPED)

THIS REPORT AND SCHEDULES 1074A, 1074B,

1074-B

RECEIVED FROM OTHER THAN MNFR (UNSTAMPED)

1074C,1074D, 1074E AND NPM-CIG

SOLD IN DELAWARE

ARE TO BE FILED WITH THE

1074-C

SOLD TO DELAWARE AFFIXING AGENTS

DELAWARE DIVISION OF REVENUE,

1074-D

SOLD OUTSIDE DELAWARE

P.O. BOX 2340, WILMINGTON, DE 19899, ON OR

1074-E

SOLD TO EXEMPT ORGANIZATIONS IN DELAWARE

BEFORE THE 20TH DAY OF EACH MONTH FOR

NPM

PRODUCTS PURCHASED FROM NPM

THE PRECEDING MONTH, BY EVERY

DESTROYED, LOST OR STOLEN (STAMPED)

WHOLESALER IN DELAWARE. WHOLESALE

DESTROYED, LOST OR STOLEN (UNSTAMPED)

DEALERS WHO HAVE A DELAWARE PERMIT BUT

RETURNED TO MANUFACTURERS (STAMPED)

WHO ARE SITUATED OUTSIDE DELAWARE MUST

RETURNED TO MANUFACTURERS (UNSTAMPED)

FILE MONTHLY REPORTS ON FORM 1075

INVENTORY AT END OF MONTH (STAMPED)

INVENTORY AT END OF MONTH (UNSTAMPED)

STAMP ACCOUNT

STAMPS

$0.55

$0.69

ON HAND BEGINNING OF MONTH (UNAFFIXED)

RECEIVED FROM DOR DURING MONTH

SUBTOTAL

STAMPS AFFIXED DURING MONTH

(

) (

)

ON HAND AT END OF MONTH (UNAFFIXED)

AFFADAVIT:

I hereby swear under penalty of perjury that the foregoing return has been examined by me and that all information contained herein, including any accompanying schedules or statements is true and correct; and that this

constitutes a complete return for the month stated, pursuant to law. I also swear that the licensee is in compliance with the UNFAIR CIGARETTE SALE ACT, Chapter 26 of Title 6 of the Delaware Code.

_______________________________________________

_____________________________

______________________

SIGNATURE OF LICENSEE OR OFFICER THEREOF

TITLE

DATE