RESIDENT
REV-1030 AS+ (06-11)
STAMP AFFIXING AGENCY
FEDERAL EIN:
MONTHLY REPORT
OF CIGARETTES AND CIGARETTE
FOR THE MONTH OF
TAX STAMPS
BUREAU OF BUSINESS TRUST FUND TAXES
PO BOX 280909
HARRISBURG PA 17128-0909
YEAR
Please print or type.
NAME
CSA NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
Reporting instructions (DAS-29) are avialable online at
LINE
SECTION 1 - UNSTAMPED CIGARETTE ACCOUNT
COLUMN 1
COLUMN 2
COLUMN 3
1
OPENING INVENTORY - UNSTAMPED
2
OPENING INVENTORY - STAMPED FOR OTHER STATES
TOTAL INVENTORY - ADD LINES 1 AND 2
3
4
PURCHASES FROM MANUFACTURER - SCHEDULE A
5
PURCHASES FROM OTHERS - SCHEDULE B
6
SAMPLE CIGARETTES - NON TAX PAID
TOTAL - ADD LINES 3 THROUGH 6
7
8
SOLD OUTSIDE PENNSYLVANIA - SCHEDULE D
9
SOLD TO TAX-EXEMPT AGENCIES - SCHEDULE C
10
RETURNED TO MANUFACTURER - SCHEDULE A-1, COL. 5
11
LOST IN TRANSIT/SHORTAGES - SCHEDULE A-1, COL. 5
12
DAMAGED AND REFUSED - SCHEDULE A-1, COL. 5
13
CANCELLED FROM ORDERS - SCHEDULE A-1, COL. 5
14
OTHER
15
CLOSING INVENTORY - UNSTAMPED
16
CLOSING INVENTORY - STAMPED FOR OTHER STATES
TOTAL INVENTORY - ADD LINES 15 AND 16
17
ADD LINES 8 THROUGH 14 AND 17
18
BALANCE TAXABLE - SUBTRACT LINE 18 FROM LINE 7
19
TAX RATE
$
0.08
20
AMOUNT OF TAX DUE - MULTIPLY LINE 19 BY LINE 20
$
21
STAMPS
STAMPS
SECTION 2 - STAMP ACCOUNT
VALUE
1.60
2.00
0.80
22 OPENING INVENTORY - UNAFFIXED
23 PURCHASED FROM DEPARTMENT
24 OTHER:
25 TOTAL - ADD LINES 22 THROUGH 24
26 RETURNED TO DEPARTMENT
27 USED FOR RE-STAMPING
28 OTHER:
29 CLOSING INVENTORY - UNAFFIXED
30 TOTAL - ADD LINES 26 THROUGH 29
31 STAMPS USED - SUBTRACT LINE 30 FROM LINE 25
$
32 CONVERT TO STICKS
X 20
X 25
X 10
TOTAL
33 STICKS PA STAMPED - MULTIPLY LINE 32 BY LINE 31
RECONCILIATION
34
AMOUNT OF TAX DUE FROM LINE 21 $
36 ADDITIONAL TAX DUE
$
35
VALUE OF STAMPS USED LINE 31
$
37 VALUE OF EXCESS STAMPS USED $
NOTE: PA STAMPED CIGARETTE ACCOUNT AND SCHEDULE A ON REVERSE SIDE
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