Form Rev-1164 - Monthly Pact Act Report
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1
2REV-1164 AS (12-11)
MONTHLY PACT ACT REPORT
BUREAU OF BUSINESS TRUST FUND TAXES
Tobacco Sales Report
PO BOX 280909
HARRISBURG, PA 17128-0909
START
Step 1: Identify your business.
HERE
Reporting period
(Month/Year).
Due Date: 10th day of the month following the month in which roll-your-own and smokeless tobacco, were shipped. See reverse for important
information and mailing instructions.
Business Name
Federal EIN
Mailing Address: Number and street
PA License Number
City
State
ZIP
Business Telephone Number
Country/Territory
Contact Name
Email Address
Contact Telephone Number
Step 2: Identify your sales into Pennsylvania.
Attach additional sheets as needed.
Date:
Invoice:
License #:
FEIN:
Brand:
UPC:
Type:
Total Weight:
Quantity:
Wholesale List Price:
Buyer:
Buyer Address:
Sale Price:
Deliverer:
Deliverer Address:
Phone Number:
Date:
Invoice:
License #:
FEIN:
Brand:
UPC:
Type:
Total Weight:
Quantity:
Wholesale List Price:
Buyer:
Buyer Address:
Sale Price:
Deliverer:
Deliverer Address:
Phone Number:
Date:
Invoice:
License #:
FEIN:
Brand:
UPC:
Type:
Total Weight:
Quantity:
Wholesale List Price:
Buyer:
Buyer Address:
Sale Price:
Deliverer:
Deliverer Address:
Phone Number:
Date:
Invoice:
License #:
FEIN:
Brand:
UPC:
Type:
Total Weight:
Quantity:
Wholesale List Price:
Buyer:
Buyer Address:
Sale Price:
Deliverer:
Deliverer Address:
Phone Number:
Date:
Invoice:
License #:
FEIN:
Brand:
UPC:
Type:
Total Weight:
Quantity:
Wholesale List Price:
Buyer:
Buyer Address:
Sale Price:
Deliverer:
Deliverer Address:
Phone Number:
Step 3: Sign below
Under penalties of perjury, I verify I examined this report, and to the best of my knowledge, it is true, correct and complete. I also verify such
information is taken from the books and records of the business for which this return is filed.
PLEASE SIGN AFTER PRINTING.
Signature of Owner/Officer
Title
Phone Number
Date
PLEASE SIGN AFTER PRINTING.
Signature of Owner/Officer
Title
Phone Number
Date
Reset Entire Form
PRINT FORM
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