Form Pa-2 - State Tobacco P.a.c.t. Act Report

ADVERTISEMENT

PA-2
State Tobacco P.A.C.T. Act Report
Step 1: Identify your business
Name:
Reporting period: __ __/__ __ __ __
_________________________________________________
(Month/Year)
Address:
License no.: ____________________________
_______________________________________________
Number and street
Federal Employer Identification number:____-______________
_______________________________________________________
City State/Province ZIP
(FEIN)
Country/Territory: ___________________________________
Phone: (_____)______- ___________ Ext:__________
Contact name: _ _____________________________________
Email address:___________________________________
Step 2: Identify your sales into ____________________
Identify the state
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address City State ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address City State ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address City State ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address City State ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address City State ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address City State ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address City State ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address City State ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address City State ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address City State ZIP
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report, and, to the best of my knowledge, it is true, correct, and complete. I also
state that such information is taken from the books and records of the business for which this report is filed.
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title) Telephone number (include area code) Date
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title) Telephone number (include area code) Date
PA-2 (N-11/10)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2