Form Ct-23 - Schedule B - Shipments Of Unstamped Cigarettes Made To Agencies Of The Federal Government Or Connecticut State Government

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Department of Revenue Services
Form CT-23
PO Box 5031
Hartford CT 06102-5031
Schedule B
(Rev. 06/07)
Shipments of Unstamped Cigarettes Made to
Agencies of the Federal Government or Connecticut State Government
Name of Distributor __________________________________________ CT Tax Registration Number __________________________
Address of Distributor ____________________________________________________________ Month of ____________ 20 ________
1. Enter all shipments of unstamped cigarettes made to agencies of the federal or Connecticut state government.
2. Provide the address to which the cigarettes were actually delivered.
3. The total of Form CT-23, Schedule B, should agree with the amount reported on Line 15 of Form CT-15, Monthly Tax Stamp and
Cigarette Report, Resident Distributor. Forward Form CT-23 to the Department of Revenue Services with Form CT-15.
Number of
Date
Name of Agency and Address Where Cigarettes Were Delivered
Invoice Number
Cigarettes
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
Total
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
Continue on reverse side if necessary.

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