Form Cig 95 - Report Of Out-Of-State Sales Of Cigarettes
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CIG 95
Report of Out-of-State Sales of Cigarettes
Rev. 3/09
Complete a separate form for each state in which cigarettes were sold.
File in duplicate*
P.O. Box 530
Columbus, OH 43216-0530
Cigarettes transferred into (list state)
Month
Year
20
Name
FEIN
DBA
Social Security number
Street address
Cigarette license number
City
State
ZIP code
Ohio’s wholesale account number
Columns
6. Number of packages of 25s (only required if your state requires you to report in pack quantities).
1. Date of shipment or transfer out of state.
7. Number of packages of other pack sizes (only required if your state requires you to report
in pack quantities).
2. Indicate how shipped: DT, Distr Truck; CC, Common Carrier; PP, Parcel Post; CT, Customer Truck.
8. The total number of sticks per invoice (only required if your state requires you to report in
3. Invoice number of product shipped into another wholesaler.
stick quantities).
4. Complete name, address and city of company or person to whom cigarettes were sold.
9. Indicate whether shipped cigarettes were tax paid (only in states where untaxed shipments
5. Number of packages of 20’s (only required if your state requires you to report in pack quantities).
are allowable).
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Date
How
Invoice
Name and Address of Buyer
# of Packs
# of Packs
Other
# of Cigarettes
Tax Paid
Shipped
Number
(20s)
(25s)
(specify)
(total sticks)
(yes/no)
*This report is to be made in triplicate. Mail original and copy to Ohio Department of Taxation, Excise
Subtotal: This page only
Tax Section, P.O. Box 530, Columbus, OH 43216-0530. Retain additional copy for your fi les.
Grand total
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