Schedule Ct-1b - Sales To Agencies Of The United States

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Rev. 6/12
Schedule CT-1B
Massachusetts
Sales to Agencies
Department of
of the United States
Revenue
This is to acknowledge receipt of untaxed cigarettes, herein described, which have been purchased by an authorized post exchange or ships
service store or for use by the United States government, and to certify that the sale of such cigarettes will be made only in accordance with
the regulations governing such agency.
Name of wholesaler
Date of sale
Invoice number
Wholesaler address
City/Town
State
Zip
Name of agency
Agency address
City/Town
State
Zip
Brand of cigarettes
Quantity
Brand of cigarettes
Quantity
Brand of cigarettes
Quantity
Total. Enter on Form CT-1, line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The undersigned certifies under the penalties of perjury that all lines and statements herein contained or upon schedules attached hereto are true and
accurate in every particular.
Signature of authorized agent
Title
Date
This acknowledgment must be made for each sale of cigarettes to the United States or an agency thereof, and made a part of the monthly ciga-
rette excise report. No deduction of the excise will be allowed on Form CT-1, line 4 unless the sale is made to an authorized agency and acknowl-
edgment is properly signed by an authorized employee of the United States government.

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