Fillable Form 69-311 - Cigarettes Delivery Sales Statement printable pdf download

Form 69-311 - Cigarettes Delivery Sales Statement

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69-311

PRINT FORM

CLEAR FIELDS

(10-03)

STATE OF TEXAS

For Comptroller Use

Only

00990

8870

CIGARETTES DELIVERY SALES STATEMENT

SELLER

a.) Business taxpayer number:

Permit number

b.) Date of Sale

c.) Business name:

d.) Business location:

e.) City:

County

f.) State:

g.) Zip Code

h.) Email or web page address:

As a fully authorized representative, I am the

for the above named business. I’m over

Business Position

18 years of age, am competent to make this statement, and have personal knowledge of the facts stated herein. I hereby

certify that no Texas cigarette tax is due on the cigarette packages enclosed in this shipment that is to be delivered to the

name and address in the “purchaser” section of this form mentioned below. I am familiar with Texas law regarding the

delivery sales of cigarettes and all applicable tax payments and reporting requirements imposed by the Texas Tax Code.

The content within this package is in full compliance with Chapter 154 of the Texas Tax Code and Chapter 161 of the Texas

Health & Safety Code. I certify that I am authorized to sign this statement on behalf of the business named above.

PURCHASER

i.) Legal Name:

j.) Delivery or mailing address:

k.) City

l.) State

m.) Zip Code

n.) Daytime phone number

DELIVERY SERVICE PROVIDER

o.) User Texas Outlet number

p.) Name

q.) Address

r.) City

s.) State

t.) Zip code

u.) Email Address

Signature of Authorized Representative for Seller

Print Name of Authorize Representative for Seller

Signature of Authorized Representative for Delivery Service Provider

Print Name of Authorized Representative for Delivery Service Provider

Mail Original to:

TEXAS COMPTROLLER OF PUBLIC ACCOUNTS

P.O. BOX 13528

AUSTIN, TX 78711

Please, retain a copy for your records.

You have certain rights under Ch. 559, Government Code, to review, request, and correct information we have on file about you. Contact us at the address or toll-free number listed on this form.

Form 69-311 - Cigarettes Delivery Sales Statement

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