Form Rev-1030 - Resident Stamp Affixing Agency Monthly Report Of Cigarettes And Cigarette Tax Stamps Page 2

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REV-1030 AS+ (06-11)
STAMP AFFIXING AGENCY
MONTHLY REPORT
FOR THE MONTH OF
OF CIGARETTES AND CIGARETTE
BUREAU OF BUSINESS TRUST FUND TAXES
TAX STAMPS
PO BOX 280909
YEAR
Please print or type.
HARRISBURG PA 17128-0909
LINE
SECTION 3 - PA STAMPED CIGARETTE ACCOUNT
COLUMN 1
COLUMN 2
1
OPENING INVENTORY - PA STAMPED
2a
PA TAX STAMPS USED FOR CIGARETTES
2b
PA TAX STAMPS USED FOR LITTLE CIGARS
2c
TOTAL PA TAX STAMPS USED - FROM SECTION 2, LINE 33
3
PURCHASED FROM OTHERS - SCHEDULE B
TOTAL PA STAMPED - ADD LINES 1, 2C AND 3
4
5
RETURNED TO MANUFACTURER
6
DESTROYED OR STOLEN
7
OTHER
8
CLOSING INVENTORY PA STAMPED
TOTAL - ADD LINES 5 THROUGH 8
9
AVAILABLE FOR SALE - SUBTRACT LINE 9 FROM LINE 4
10
11
SALES IN PENNSYLVANIA
SALES OVER OR (UNDER) - SUBTRACT LINE 10 FROM LINE 11
12
SCHEDULE A - UNSTAMPED CIGARETTES RECEIVED FROM MANUFACTURERS
DURING MONTH (FROM SCHEDULE A-1, COL. 4)
NON TAX PAID
NAME OF MANUFACTURER
FOR DEPARTMENT USE ONLY
(UNSTAMPED)
TOTAL (ENTER ON SECTION 1, LINE 4)
REMARKS:
FOR DEPARTMENT USE ONLY
RECEIVED
ACCEPTED
RETURNED
CONTROL
SCHEDULE A-1
SCHEDULE A-1
I declare under the penalties of perjury this monthly report, including any accompa-
nying statements, has been examined by me and to the best of my knowledge and
belief is a true, correct and complete monthly report.
Signature
Title
Date
INSTRUCTIONS:
1.
This report and its schedules shall contain a complete account of all cigarettes and cigarette tax stamps handled
during the reporting period.
2.
Schedules A-1, B, C, F and two copies of Schedule D must accompany this report where applicable.
3.
This report must be prepared in duplicate; the original must be filed with the PA Department of Revenue, and the
duplicate must be retained by cigarette stamping agent for at least four years.
4.
The report is due on the 20th day after the end of the month for which it is prepared.

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