Form Rev-1042 - Cigarette Tax Exemption Certificate
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2REV-1042 (12-09)
CIGARETTE TAX
EXEMPTION CERTIFICATE
BUREAU OF BUSINESS TRUST FUND TAXES
PO BOX 280909
HARRISBURG PA 17128-0909
SEE REVERSE SIDE FOR INSTRUCTIONS
SELLER:
NAME
LICENSE NUMBER
ADDRESS
PURCHASER:
NAME
LICENSE NUMBER
ADDRESS
Type of exemption (mark one):
Out-of-state little cigar sales
Cigarette tax exemption within the provisions 72 P.S. § 8209.
DATE
INVOICE NUMBER QUANTITY
BRAND
PRICE
1.
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13.
TOTALS
I acknowledge receipt of the above-named cigarettes and/or little cigars and certify that I read the instructions on the reverse side of
this Exemption Certificate. The facts submitted are accurate and complete to the best of my knowledge, information and belief.
SIGNATURE
OFFICIAL TITLE
DATE
Misuse of this Exemption Certificate is a violation of Pennsylvania law and the regulations promulgated thereunder.
Additional information, forms and copies of cigarette tax regulations may be obtained online at or by
writing to the PA Department of Revenue, Bureau of Business Trust Fund Taxes, PO Box 280909, Harrisburg, PA 17128-0909.
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