Delivery Service Information Report - Tennessee Department Of Revenue printable pdf download

Delivery Service Information Report - Tennessee Department Of Revenue

TENNESSEE DEPARTMENT OF REVENUE

Please complete this form each month in full

Delivery Service Information Report

and mail to:

TENNESSEE DEPARTMENT OF REVENUE

500 Deaderick Street

Nashville, TN 37242

1. Filing Period

Filing Period

2. Business Information

Name

FEIN

Address

City

State

Zip

Telephone Number

Email Address

3. Sales Information

Brand Family of

Delivery

Cigarettes, RYO

Designate

Service

Delivery Service

Date of

Shipped to:

Shipped to: Address

or Smokeless

C, RYO

Quantity

Company

Company Address and

Shipment

Name

and Telephone Number

Tobacco

or S

Sold

Sales Price

Name

Telephone Number

Title 15 U.S. code §§ 375-378, the Jenkins Act, as amended by the PACT Act, requires that any person who sells or transfers cigarettes for profit into Tennessee, must file a memorandum with DOR

showing each and every shipment of cigarettes made into Tennessee during the previous calendar month. The memorandum, which is due no later than the 10

day of each month, must include the

name and address of the person to whom the shipment was made and the quantity of cigarettes.

Print Name

Signature of Preparer

Date