Form Rev-1036 - Nonresident Stamp Affixing Agency Monthly Report Of Cigarettes And Cigarette Tax Stamps Page 2

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REV-1036 AS+ (06-11)
PA STAMPED
CIGARETTES RECEIVED
BUREAU OF BUSINESS TRUST FUND TAXES
SCHEDULE A
PO BOX 280909
HARRISBURG PA 17128-0909
Please print or type.
Receipts of all stamped cigarettes during the
NAME OF LICENSEE
month of:
STREET ADDRESS
CITY
STATE
ZIP CODE
___________________________ 20
FOR DEPARTMENT USE ONLY
INVOICE
NAME AND ADDRESS OF LICENSEE
DATE
NUMBER
(From Whom Received)
TOTAL
TOTAL PA STAMPED CIGARETTES RECEIVED (ENTER ON LINE 3.)

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