Form 73a420 - Monthly Report Of Cigarette Wholesaler Page 3

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73A420 (2-12)

Page 3

SCHEDULE B—Sales to Subjobbers—List names and addresses of all persons to whom Kentucky stamped cigarettes were sold on a “wholesaler to wholesaler” price basis during

month. List any additional names on a separate sheet.

Name

Address

SCHEDULE C—Packages Sold to Tax-Exempt Agencies and Institutions—If necessary, list additional names on separate sheet and attach to this form.

Number of Packages

Name

Address

20’s

Other (specify)

Total must agree with amount shown in column (a) on line 6. ............................................................................................... ➤

TOTAL

➤ IMPORTANT:  I agree to allow the Kentucky Department of Revenue or the Attorney General to release to the manufacturer information which

I have provided on page 4 of Revenue Form 73A420, Monthly Report of Cigarette Wholesaler, about cigarettes purchased from

the manufacturer. I understand that this information might ultimately become part of an official court record if an enforcement

action is taken against that manufacturer.



I, the undersigned, declare under penalties of perjury that I have examined this return, pages 1 through 4 and to the best of my knowledge and belief, it is

true, correct and complete.

Print Name _________________________________________________

Title or Position ________________________________________

Signature __________________________________________________

Date _________________________________________________

E-mail Address _____________________________________________

Telephone Number _____________________________________

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