Form R-5604-B(P - Schedule Of Purchases Tobacco Tax

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R-5604-B(P) (11/13)
Tobacco Tax
Schedule of Purchases
Dealer ____________________________________________
Period ____________________________________________
Address _____________________________________________________________________________________________
(2)
(3)
(4)
(1)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
Gross tax value
PM or NPM
Smoking
cigars and
Cigar Mfg.’s
Cigar mfg.’s
Invoice
Product
Number of
tobacco mfg.’s
Smokeless
smoking
list price
list price
Date
Number
Date rec’d
Vendor or Vendee
Manufacturer
Brand
PM
NPM
cigarettes
list price
tobacco/OTP
tobacco
(up to $120/M)
(over $120/M)
$
$
$
$
$
To Tobacco Tax Return Line 2
$
To Tobacco Tax Return Line 23A
$
To Line 23B
$
To Line 23C
$
To Line 23D
$
Total

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