Form Das-34 (Schedule C) - Cigarettes Sold To Tax Exempt Organizations During Month

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DAS-34 (11-10)
FEDERAL EIN: __________________________________
SCHEDULE “C”
CIGARETTE LICENSE NUMBER:
BUREAU OF BUSINESS TRUST FUND TAXES
PO BOX 280909
Please Print Clearly
HARRISBURG PA 17128-0909
MM/DD/YY
NAME
DATE:
ADDRESS
REPORT MONTH:
YEAR:
CIGARETTES SOLD TO TAX EXEMPT ORGANIZATIONS DURING MONTH
TAX PAID
NONTAX PAID
NAME AND ADDRESS
(UNSTAMPED )
(PA STAMPED)
Total (REV-1030 ENTER ON LINE 9, REV-1036 ENTER ON LINE 7)
Reset Entire Form

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