Form 1075 - Non-Resident Wholesale Dealer'S Monthly Report Of Cigarette And Cigarette Tax Stamps - 2013 Page 2

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STATE OF DELAWARE
FORM 1075-A
MONTH OF ________________________, 20___
DIVISION OF REVENUE
NON-RESIDENT WHOLESALER
CIGARETTES SOLD IN DELAWARE
NAME: _________________________________________
EMPLOYER IDENTIFICATION NUMBER: _____________________________________
DATE
NAME
ADDRESS
20'S
25'S
TOTAL
TOTAL
*DF40213029999*

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