Indiana Department of Revenue
P.O. Box 901
Indianapolis, IN 46206-0901
CT-5
LICENSED CIGARETTE DISTRIBUTOR’S
SF 46855
MONTHLY CIGARETTE TAX RETURN
(R3/ 3-09)
For the period of ______________________, 20____
Name of License Holder (as indicated on license)
Mailing Address
Cigarette Distributor’s License#
City or Town
County
State
Zip Code
Federal ID Number
CIGARETTE STOCK ACCOUNT
1. Beginning Inventory of Unstamped Cigarettes.......................................................................................
1.
2. Purchases of Unstamped Cigarettes (From attached Schedules CT-12A and CT-12B)........................
2.
3. Total Inventory (Add Lines 1 and 2).....................................................................................................
3.
4. Ending Inventory of Unstamped Cigarettes (From attached Schedule CT-11)......................................
4.
5.
Sales in Interstate Commerce (From attached Schedule CT-12D).........................................................
5.
Individual
A
B
C
D
State Totals
6.
6. Sales to Indiana Licensed Distributors (From attached Schedule CT-12E)...........................................
7.
7. Total Deductions (Add Lines 4, 5 and 6)...............................................................................................
8. Number of Cigarettes Stamped (Line 3 minus Line 7)..........................................................................
8.
9. Tax on Cigarettes (Multiply Line 8 by current tax rate)........................................................................
9.
CIGARETTE TAX STAMP ACCOUNT
A
B
C
Full Roll
Partial Roll and Wides
25’s
Stamps $ Value
Stamps $ Value
Special Stamps $ Value
1. Beginning Inventory of Tax Stamps
2. Purchases of Tax Stamps (From
attached Schedule CT-11)
3. Total Inventory (Add Lines 1 and 2)
4. Ending Inventory of Tax Stamps
(From attached Schedule CT-11)
5. Total Stamps Used (Line 3 minus Line 4)
6. Total Cigarette Tax Stamps Used (Add Line
5 of columns A, B and C)
I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and state-
ments, is true, correct and complete to the best of my knowledge and belief.
Signature of Taxpayer or Agent
Title
Telephone Number
Date
(
)
IMPORTANT: A RETURN MUST BE FILED EACH MONTH WITHIN 15 DAYS FOLLOWING THE LAST DAY OF THE
PERIOD BEING REPORTED.
Questions related to this form, call (317) 615-2710