Form R-5604-B(C) - Schedule Of Credits Tobacco Tax

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R-5604-B(C) (11/13)
Tobacco Tax
Schedule of Credits
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)
$
$
$
$
$
Amount reported on the applicable lines of Tobacco Tax Return (See return Instructions)
$
Amount included for Tobacco Tax Return Line 24
$
Amount included for Line 24
$
Amount included for Line 24
$
Amount included for Line 24
$
Total amount included for Line 24

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