Form 69-109 - Texas Distributor Receiving Record Of Cigarette Tax Stamps
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269-109
(Rev.7-09/3)
b.
TEXAS DISTRIBUTOR RECEIVING RECORD OF CIGARETTE TAX STAMPS
(Attach this form to your Texas Distributor Monthly Report of Cigarettes and Stamps, Form 69-100, for the same filing period.)
a. Taxpayer number
c. Filing period
Month ending _______________________________
d. Taxpayer name
e. Physical address of permitted location (Street)
City
State
ZIP Code
1.
2.
3.
4.
5.
RECEIVED
REGISTERED
INVOICE
NUMBER
NUMBER
DATE
NUMBER
NUMBER
OF 20’s
OF 25’s
6.
STAMP TOTALS
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Parent category: Financial