Schedule C1 (Cigarettes)

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State of Washington
Department of Revenue
Schedule C1 (Cigarettes)
Reset This Form
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
to
Manufacturer/Distributor Name
Registration No.
Warehouse Location
Product
Stamp
Name of Purchaser or
Invoice
Brand Family
Description
Total Sticks
Delivery Address
Invoice Date
1
Code
Receiver
Number
(Optional)
0
1
See stamp codes on instructions
Page Total
Note: If multiple pages reported, please sign on last page.
Grand Total
Signature: ________________________________________________ Phone: _______________________________________
Print: ________________________________________________Date: _______________________________
Note for In-State Distributor’s report of interstate sales: If cigarettes have 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”.
Print This Form
REV 82 2103e-C1 (10/28/10)

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