Form Rev 82 2107-2 - Non-Participating Manufacturer Reporting Form Page 2
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1
2Washington State
Non-Participating Manufacturer
Department of Revenue
Return the completed form 25 days after the
Special Programs Division
Reporting Form
close of the reporting month.
PO Box 47477
Olympia, Washington 98504-7477
Instructions on reverse side
Please complete this schedule in full and mail to:
Washington State Department of Revenue,
Please provide the following information with respect to cigarettes sold that were manufactured
Special Programs Division, PO Box 47477,
by a Non-Participating Manufacturer (NPM). To report sales of cigarettes to Indian Tribes with a
Olympia WA 98504-7477
cigarette tax contract, please use form 82-2109.
Tax Reporting
Account No:
Name:
Reporting Month/Yr:
mm/yy
No. of
Ounces of Roll-
Cigarettes Sold
Your-Own
Name & Address of the Person
Name & Address of the First
in Washington
Tobacco Sold in
Non-Participating Manufacturer
From Whom Each Cigarette
Importer of Foreign
(a)
Washington
Brand Name
Name & Address
Was Purchased
Manufactured Cigarettes
(b)
(c)
(d)
(e)
(f)
This report is subject to future verification by the Department of Revenue.
Reset This Form
Phone:
Signature:
Date:
REV 82 2107-2 (06/20/05)
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