Form B-A-101r - Application For Other Tobacco Products Excise Tax Refund For North Carolina Tax-Paid Other Tobacco Products Returned To Manufacturer

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B-A-101R
Application for Other Tobacco Products
Web
Excise Tax Refund for North Carolina Tax-Paid
8-12
Other Tobacco Products Returned to Manufacturer
North Carolina Department of Revenue
DOR Use Only
Return for Month Ended
(MM-DD-YY)
(Date returned to manufacturer)
Legal Name (First 35 Characters)
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
FEIN or SSN
Trade Name
Mailing Address
City
State
Zip Code
NCDOR ID/Account Number
State of Domicile
Name of Contact Person
Phone Number
Fax Number
Computation of Refund for North Carolina Tax-Paid Other Tobacco Products
1. Total Cost Price of Other Tobacco
Products Returned to Manufacturer
,
,
,
.
1.
00
Cost price is the price paid for the products before any discount,
rebate, or allowance. (Attach copies of invoices or equivalent information.)
12.8%
2.
Refund Rate for Returned Other Tobacco Products
2.
,
,
,
.
3.
Refund Due
3.
00
Multiply Line 1 by Line 2
,
,
,
.
4.
Discount
4.
00
Multiply Line 3 by 2%
,
,
,
.
5.
Total Refund Due
5.
00
Line 3 minus Line 4
Signature:
Title:
Date:
I certify that, to the best of my knowledge, this return is accurate and complete.
An original manufacturer’s affidavit and a copy of the manufacturer’s credit memo MUST be attached to this
application. Absent conclusive proof that other tobacco products were returned to the manufacturer at the tax rate
effective on or after September 1, 2009 will result in the denial of refund.
North Carolina Department of Revenue, PO Box 25000, Raleigh, North Carolina 27640-0001

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