Form Rev 82 2114e - Roll-Your-Own (Ryo) Cigarette Reporting Form
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1
2Washington State
Department of Revenue
Roll-Your-Own (RYO) Cigarette
Return this completed form no later
Special Programs Division
PO Box 47477
Reporting Form
than 25 days after the close of the
Olympia, Washington 98504-7477
reporting month
See instructions on reverse side
Tax Reporting Account No:
Business Name:
Reporting Month/Yr:
Month/Year
Commercial Cigarette-Making Machine Address:
1. Cigarette Tubes/Papers Sold per Customer Invoices
Total
2. Cigarettes Produced Based on Commercial Cigarette-Making Machine(s) Meter Count:
Beginning Meter
Ending Meter Count
Net Meter Count
Adjustments*
Cigarettes Produced
Count
(B)
(C)
(D)
(E)
Must be
(A)
Equal
Machine #1
Machine #2
Machine #3
Total
*Provide explanation for any adjustments, see instructions on reverse side.
3. Brand and Amount of Tobacco per This Location:
Ounces sold, but
Certified Tobacco
Brand Name of
not used to Make
Tobacco Manufacturer Name & Address
Product?
Ounces Purchased
Tobacco Used
Cigarettes in the
(B)
(Yes/No)
(D)
(A)
Store
(C)
(E)
Contact Person:
Phone:
Date:
For tax assistance or to request this document in an alternate format, visit or call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718.
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REV 82 2114e (6-14-12)
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