Form B-A-19 - Statement Of Basis For Cigarette Excise Tax Refund
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1B-A-19
Statement of Basis for Cigarette
Web
Excise Tax Refund
5-11
North Carolina Department of Revenue
DOR Use Only
Legal Name (First 35 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Trade Name
FEIN or SSN
Mailing Address
City
State
Zip Code
Name of Contact Person
State of Domicile
NCDOR ID/License Number
Phone Number
Fax Number
This is to certify that I, ________________________________________________________ , an agent of the Department of Revenue,
did on the __________________ day of __________________________ , ________________ , destroy the following North Carolina
(Month)
(Year)
Tax-Paid cigarette packs in the possession of the qualified North Carolina distributor under the North Carolina Tobacco Products Tax Act.
(1)
(2)
(3)
(4)
No. Packs of
No. Packs of
No. Packs of
Reason for Destruction
Twenty
Twenty-Five
Other
Gross Tax Value
45¢
56 1/4¢
(Specify)
A. Packs destroyed (not returnable to
,
,
,
,
,
,
.
manufacturer) as N.C. tax-paid under
00
Reporting Method (effective 1/1/94)
,
,
,
,
,
,
.
B. Other (Specify)
00
,
,
,
,
,
,
.
C. Totals
00
,
,
Total Amount of This Claim for Tax Refund
.
(Add totals of columns 1 through 4)
00
The destruction of the tax-paid packs listed above was done in the following manner so as to preclude the sale of such packs and to
preclude any further claim for a cigarette tax refund with respect thereto:
Therefore, pursuant to the North Carolina Tobacco Products Tax Act, the above named qualified distributor is entitled to a cigarette excise
tax refund in the net amount of $ ___________________________________ .
Signature of Revenue Agent:
Date:
I, ____________________________________________________________ , the above named qualified cigarette distributor, concur in
the count of North Carolina Tax-Paid cigarette packs destroyed by the above agent of the North Carolina Department of Revenue.
Signature:
Date:
Authorized signature on behalf of distributor
North Carolina Department of Revenue, Tobacco Products Tax Unit, PO Box 25000, Raleigh, North Carolina 27640-0110
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