Form Fr-1000q - Tobacco Products Excise Quarterly Tax Return - 2012

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Government of the
2012
FR-1000Q
*121000110000*
District of Columbia
TOBACCO PRODUCTS EXCISE
QUARTERLY TAX RETURN
Important: Print in CAPITAL letters using black ink
Important: Print in CAPITAL letters using black ink
OFFICIAL USE ONLY
Vendor ID# 0000
Taxpayer Identifi cation Number
Fill in
if this is your fi nal return
Quarterly Reporting Period:
Transaction Number
January - March
due April 21, 2012
April - June
due July 21, 2012
July - September
due October 21, 2012
October - December
due January 21, 2013
Business name
Business mailing address line #1
Business mailing address line #2
City
State
Zip Code + 4
TOBACCO PRODUCTS SUBJECT TO TAX DURING THE REPORT PERIOD
Column A - PRODUCT TYPE
Column B - QUANTITY
Column C - TAX RATE
Column D - TAX
(Multiply Column B by Column C)
1. Little Cigars
.00
(number)
$0.125 per little cigar
2a. Chewing Tobacco
.00
(net weight in ounces)
$0.75 per ounce
2b. Snuff
.00
(net weight in ounces)
$0.75 per ounce
2c. Roll your own Tobacco
.00
(net weight in ounces)
$0.75 per ounce
2d. Hookah Tobacco
.00
(net weight in ounces)
$0.75 per ounce
2e. Other tobacco products not listed above
Attach separate list (see instructions)
.00
(net weight in ounces)
$0.75 per ounce
3. DC Tax Due (Add Lines 1 - 2e in Column D) .....................................................................
.00
4. Penalty -
..........
5% per month with a maximum of 25% (see instructions)
.00
5. Interest -
...................................
10% per year (see instructions)
.00
6. Total DC Tax Due ..................................................................................................
Will this payment come from an account outside of the U.S.?
Yes
No
(see instructions)
Under penalties of law, I declare that this return is correct, to the best of my knowledge. Declaration of paid preparer is based on the information available to the preparer.
_________________________________________________________________________________________________________________________________________________________
Signature
_________________________________________________________________________________________________________________________________________________________
Title
Date
_________________________________________________________________________________________________________________________________________________________
Contact person (Print name)
Contact telephone number
Make your check or money order payable to DC Treasurer. Mail this form and payment to the:
Offi ce of Tax and Revenue
Audit Division, Tobacco Tax Enforcement Unit
PO Box 556
Washington, DC 20044-0556
2012 FR-1000Q
Rev. 03/12
Tobacco Products Excise Quarterly Tax Return

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