Schedule C3 (Roll-Your-Own Tobacco)

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State of Washington

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Department of Revenue

Schedule C3 (Roll-Your-Own Tobacco)

Special Programs Division

PO Box 47477

Page ______ of _________

Olympia, WA 98504-7477



Interstate shipments into Washington

Phone: (360) 570-3265

Fax:

(360) 586-2163



In-State Distributor’s report of interstate sales and/or in-state

exempt sales

Period

Manufacturer/Distributor Name

Registration No.

Warehouse Location

Quantity

Product

Tax

Quantity

Name of Purchaser or

Invoice

Description

Paid

Delivery Address

Brand Family

(Oz)

Total Ounces

Shipped

Receiver

Number

Date

(Y/N)

(Optional)

per Packing

Note: If multiple pages reported, please sign on last page.

Page Total

Grand Total

Signature: ________________________________________________ Phone: _______________________________________

Print: ________________________________________________Date: _______________________________

Note for In-State Distributor’s report of interstate sales: If roll-your-own tobacco has the tax paid for the state delivered to, you may aggregate the total of all such

sales on one line (per state) with the notation “sold tax-paid”.

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REV 82 2103e-C3 (10/28/10)