Form Rev-1140 - Little Cigars Shipping Report Weight Of Little Cigars Shipped Into The Commonwealth Of Pennsylvania

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REV-1140 AS (9-10) FI

LITTLE CIGARS SHIPPING REPORT

WEIGHT OF LITTLE CIGARS

SHIPPED INTO THE COMMONWEALTH OF PENNSYLVANIA

Business Trust Fund Taxes

9th Floor, Strawberry Sq.

Harrisburg, PA 17128-0900

Effective Nov. 1, 2009, any person shipping little cigars into Pennsylvania is required to file a report with the PA Department of Revenue. If the shipper is not a manufacturer, then

the shipper must get the information from the manufacturer; this requirement applies to retailers that purchase directly from manufacturers. Little cigars can only be shipped to

licensed cigarette dealers in Pennsylvania.

Manufacturer/Shipper Identification

START

Business Name

FEIN/Importer Number

Business Address

City

State

ZIP Code

Mailing Address

City

State

ZIP Code

Telephone

Fax

Web Address

Shipping Date (MM/DD/YY):

This schedule must be completed and filed with the department within 14 days of shipment of little cigars. Attach a separate sheet if more space is required.

NUMBER

WEIGHT PER

INVOICE

QUANTITY

INVOICE

BUSINESS NAME

BUSINESS ADDRESS

LITTLE CIGAR

PACKAGE

STAMPABLE

PER

THOUSAND

DATE

SOLD

NUMBER

SHIPPED TO

BRAND NAME

TYPE

(Y OR N)

PACKAGE

SHIPPED

MM/DD/YY

Under penalties of perjury, the undersigned authorized agent of the company or individual filling out this form verifies that all information contained herein is true and correct.

MM/DD/YY

Authorized Signature

Name (Printed or Typed)

Title

Date

Please sign after printing.

Instructions:

1. This report must be completed and filed with the PA Department of Revenue within 14 days of the shipping date.

2. You may elect to submit invoices or a schedule of your own; however, the information noted above must be provided.

3. Mail the completed report to the DEPARTMENT OF REVENUE, PO BOX 280909, HARRISBURG PA 17128-0909 or e-mail the completed report to ra-btftmisctax@state.pa.us.

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