Form 1074 - Resident Wholesale Dealer'S Monthly Report Of Cigarette And Cigarette Tax Stamps Page 7

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STATE OF DELAWARE
SCHEDULE NPM
MONTH OF __________________________, 20___
DIVISION OF REVENUE
CIGARETTE SALES OF
820 NORTH FRENCH ST.
NON-PARTICIPATING MANUFACTURER BRANDS
P.O. BOX 8911
WILMINGTON, DE 19899-8911
BUSINESS NAME & ADDRESS: _________________________________________
EMPLOYER IDENTIFICATION NUMBER: _____________________________________
CONTACT PERSON: ___________________________________________________
TELEPHONE NUMBER: ____________________________________________________
NUMBER OF CIGARETTE
NAME & ADDRESS OF THE
NAME & ADDRESS OF THE
OUNCES
NON-PARTICIPATING
PACKS SOLD
BRAND NAME
PERSON(S) FROM WHOM EACH
FIRST IMPORTER OF FOREIGN
OF RYO
MANUFACTURER NAME & ADDRESS
BRAND WAS PURCHASED
MANUFACTURED BRANDS
25'S
20'S
I certify that the above stated information is true and correct.
Signature
Date

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