Form Rev-1036 - Nonresident Stamp Affixing Agency Monthly Report Of Cigarettes And Cigarette Tax Stamps

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NONRESIDENT

REV-1036 AS+ (06-11)

FEDERAL EIN

NAME

STAMP AFFIXING AGENCY MONTHLY

ADDRESS

REPORT OF

CIGARETTES AND CIGARETTE

BUREAU OF BUSINESS TRUST FUND TAXES

CSA Number

TAX STAMPS

PO BOX 280909

Report Month

HARRISBURG PA 17128-0909

Please print or type.

Date Submitted

Reporting instructions (DAS-27) are available online at

STAMPED CIGARETTE

DO NOT USE THIS SPACE

FOR DEPARTMENT USE ONLY

LINE

ACCOUNT

CIGARETTES*

AUDIT

FOR DEPARTMENT USE ONLY

Pennsylvania stamped cigarettes on-

hand beginning of month

Number of cigarettes Pennsylvania

stamped during month from Line 20

Pennsylvania stamped cigarettes

received during month - Schedule A

Total

(Add Lines 1, 2 and 3.)

Pennsylvania stamped cigarettes

on hand at end of month

Total to be accounted for

(Subtract Line 5 from Line 4.)

Unstamped cigarettes sold to exempt

organizations - Schedule C (DAS-34)

Stamped cigarettes sold into Pennsylvania

during month - Schedule D (REV-1032,

REV-1032A)

Other credits

(Attach supporting statement.)

Total cigarettes sold into PA and credits

subject to tax (Add Lines 8 and 9.)

Sales over and under

(Subtract Line 6 from Line 10.)

PA CIGARETTE TAX STAMP ACCOUNT

LINE

DESCRIPTION

1.60

2.00

0.80

$ VALUE

Opening inventory

Purchased from department

Additional purchases

(Subject to prior departmental approval.)

Total

(Add Lines 12, 13 and 14.)

Returned to department or restamped

Closing inventory

Total Lines 16 and 17

19a

PA tax stamps used for cigarettes

19b

PA tax stamps used for little cigars

Total PA tax stamps used

19c

(Subtract Line 18 from Line 15.)

Convert to sticks

X 10

X 20

X 25

Number of sticks stamped

(Enter number on Line 2.)

* Includes stampable little cigars.

I declare under penalties of perjury this monthly report, including any accompanying statements, has been examined by me and to the best of my knowledge and

belief is a true, correct and complete monthly report.

Signature of Officer or Owner

Title