Form B-A-20 - Cigarette Manufacturer'S Affidavit (Unsalable Cigarettes)

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Cigarette Manufacturer’s Affidavit
B-A-20
Web
(Unsalable Cigarettes)
2-10
North Carolina Department of Revenue
Name of Manufacturer
Street Address of Manufacturer
Date The Manufacturer Received
the Returned Product
Zip Code
City
State
(MM-DD-YY)
From (Name of Wholesaler or Distributor)
Authorization Number
Street Address Where Original Product Was Shipped
Zip Code
City
State
The undersigned, being duly sworn, states:
1. That the unsalable cigarettes described below on which the North Carolina Cigarette Excise Tax has been paid were received
from __________________________________________________________________________
_______________________________________
Name of North Carolina Distributor
License Number
_________________________________________________________
____________________________________________________________
Street and Number
City and State
2. That all the packages of cigarettes listed above have been destroyed, and that none of the cigarettes returned by the distributor will be reshipped or
sold in the State of North Carolina.
Packs received as N.C. tax-paid under
Tax Value
No. of Cigarettes
Reporting Method (effective 1/1/94)
No. of Packs
Per Pack
Each Pack
Gross Tax Value
Brand Name
Brand Name
Brand Name
Brand Name
The undersigned states, under the penalty of perjury, that all the information contained on this form is true and accurate.
Please attach the credit memo and/or any invoices for substantiation.
Name of Manufacturer on whose behalf affidavit is made
Signature and Title of Affidavit
Date
The State of ___________________________ County of ___________________________________________________________________________
Subscribed and sworn before me a Notary Public in and for the County and State on this _____________________________________________ day of
_______________________________________ 2010.
Commission Expires
Notary Public
North Carolina Department of Revenue, Tobacco Products Unit, PO Box 25000, Raleigh, North Carolina 27640-0001

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