Form B-A-105 - Statement Of Inventory For 2009 Other Tobacco Products Excise Tax Increase
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1
2Statement of Inventory for 2009 Other
B-A-105
Web
Tobacco Products Excise Tax Increase
4-11
North Carolina Department of Revenue
DOR Use Only
Effective date
(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
Name of Contact Person
State of Domicile
Fill in circle if applicable:
Phone Number
Fax Number
Amended Return
Part 1. Computation of Increased N.C. Excise Tax on Inventory of Other Tobacco Products on Hand as of
(For more information concerning the excise tax increase, see the frequently asked questions
September 1, 2009
on the Department of Revenue’s website, )
,
,
.
1. Cost Price of Saleable North Carolina Tax-Paid Other Tobacco Products
00
1.
.
,
,
2. Cost Price of Unsaleable North Carolina Tax-Paid Other Tobacco Products (Exclude cigars)
2.
00
3. Cost Price of Unsaleable North Carolina Tax-Paid Cigars
.
,
,
3.
00
(Licensed dealers only)
,
,
.
4. Total Cost Price of North Carolina Tax-Paid Other Tobacco Products
4.
00
Add Lines 1 through 3
2.8%
5. Tax Rate - 2.8%
5.
,
,
.
6. Additional Excise Tax Due
6.
00
Multiply Line 4 by Line 5
7. Penalty (10% for late payment; 5% per month, maximum 25%, for
,
,
.
late filing) Multiply Line 6 by applicable penalty rate if return with full
7.
00
payment is not filed timely
8. Interest (See the Department’s website, , for current
,
,
.
interest rate.) Multiply Line 6 by applicable interest rate if return with
8.
00
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.
Effective September 1, 2009, the North Carolina General Assembly increased the excise tax on other tobacco products from 10%
of the cost price of products to 12.8%. Due to this increase, all wholesale dealers and retail dealers must complete an inventory of
all North Carolina tax-paid other tobacco products on hand as of September 1, 2009 and pay an additional excise tax due equal to
2.8% of the cost price of the inventory. Reports and payments are due by September 21, 2009. Mail this form with your check
or money order in U.S. currency from a domestic bank to:
North Carolina Department of Revenue, PO Box 25000, Raleigh, North Carolina 27640-0110
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