B-A-15
Cigarette Manufacturer’s Gratis Return
Web
North Carolina Department of Revenue
8-12
DOR Use Only
Return for Month Ended
(MM-DD-YY)
Legal Name (First 35 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
FEIN or SSN
Trade Name
Mailing Address
NCDOR ID/Account Number
City
State
Zip Code
State of Domicile
Name of Contact Person
Fill in circle if applicable:
Phone Number
Fax Number
Amended Return
Computation of Tax Due for Gratis Cigarettes Shipped to North Carolina
Column A
Column B
Column C
Packs of Gratis Cigarettes
Record in Packs
Record in Packs
Stick Total
of Twenty
of Twenty-Five
,
,
,
,
1.
Gratis cigarettes shipped for
1.
use in North Carolina
2.
Tax Rate: 2.25¢ Per Cigarette
.
2
45¢
56.25¢
2.25¢
(Pack of 20, Rate 45¢; Pack of 25, Rate 56.25¢)
,
,
,
,
.
.
.
Total Excise Tax Due
3.
3.
00
00
00
Multiply Line 1 by Line 2
,
,
.
4. Total Tax
4.
00
Add Columns A, B and C on Line 3
5. Discount
,
,
.
5.
Multiply Line 4 by 2% if report with full payment is
00
timely filed; otherwise enter zero.
,
,
6. Net Excise Tax Due
.
6.
00
Line 4 minus Line 5
7. Penalty
(10% for late payment; 5% per month, maximum 25%,
,
,
.
for late filing) Multiply Line 4 by rate above if return with full
7.
00
payment is not filed timely.
8. Interest
(See the Department’s website, , for
,
,
.
8.
current interest rate.) Multiply Line 4 by applicable rate if return
00
with full payment is not filed timely.
,
,
9. Total Payment Due
$
.
9.
00
Add Lines 6 through 8
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
Returns are due within twenty days after the end of the month. Form B-A-7, Tobacco Report Tax-Paid Products of Nonparticipating
Manufacturers, must be filed with this return. If there is no gratis for the month, enter zeros and remit this return by the due date.
Your check or money order must be in the form of U.S. currency from a domestic bank.
North Carolina Department of Revenue, PO Box 25000, Raleigh, North Carolina 27640-0110