Form Ct-115 - Indiana Cigarette Tax Return
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1CT-115
Do not use this space.
State Form 53437
(R2 / 3-09)
Please attach a copy of your invoice.
Indiana Cigarette Tax Return
Important: Tax is due at time of purchase.
Total retail price of the cigarettes
1
Name:
Social Security Number:
Total number of packs purchased
2
Multiply number of packs (Line 2) by 0.995
3
Date of Tax Payment:
Date Purchased:
If late include interest*
4
Make sure the address below shows through window.
If late, penalty due is 10%, or $5.00, which-
ever is greater
5
Total amount due (Add lines 3, 4 and 5)
6
Indiana Department of Revenue
*Contact the Department at (317) 615-2710 or go to our Web site
ATTN: Special Tax Division - CIGTAX
, for the current year interest rate.
P.O. Box 901
Indianapolis, IN 46206-0901
Make your check payable to:
:462060901044:
Indiana Department of Revenue - CIGTAX
Do not send cash as your payment
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