Form B-A-5 - Schedule I - Non-Tax-Paid Cigarettes Shipped, Delivered, Or Sold Outside North Carolina

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B-A-5

Non-Tax-Paid Cigarettes Shipped,

Schedule I

Delivered, or Sold Outside North Carolina

Web

North Carolina Department of Revenue

4-11

DOR Use Only

Return for Month Ended

(MM-DD-YY)

Distributor’s Name (First 35 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)

FEIN or SSN

Mailing Address

NCDOr ID/License Number

City

State

Zip Code

Name of Contact Person

State of Domicile

Shipped to State of

Phone Number

Fax Number

INSTruCTIONS

Complete the following table for all non-tax-paid cigarettes shipped, delivered, or sold outside of North Carolina during the month. List each shipment

separately using the following codes to describe the shipping method used: DT, Distributor Truck; CC, Common/Contract Carriers; PP, Parcel Post and

CT, Customer Truck. If nonparticipating manufacturing brands are sold, list each brand separately. Use a separate sheet for each state to which deliveries

were made during the month. Important: If you claim a deduction for cigarettes shipped, delivered or sold outside North Carolina on Form B-A-5,

Schedule A, Line 6, Schedule I must be attached. Failure to attach Schedule I could result in the disallowance of the deduction.

Column A

Column B

Nonparticipating

Date

Shipping

Manufacturing

Name and Address of Distributors

List in Packs of:

Shipped

Method