Form Cig 95a - Dealer'S Monthly Report Of Stamped/unstamped Cigarette Purchases From Another Licensed Ohio Wholesaler During

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CIG 59A
Rev. 11/13
Reset Form
P.O. Box 530
Columbus, OH 43216-0530
Dealer’s Monthly Report of Stamped/Unstamped Cigarette Purchases
From Another Licensed Ohio Wholesaler During
20
(Month)
Wholesaler name
Ohio cigarette tax account no.
Address
Street
City
State
ZIP code
Report of Cigarettes Received from Another Wholesaler
4
1
3
5
6
7
8
2
Date
Invoice number
Consent number to
Stamped (S) or
Wholesaler name
Wholesaler name
Wholesaler name
Wholesaler name
received
transport
Unstamped (U)
(of unstamped only)
Account number
Account number
Account number
Account number
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
(000)
Page total
(000)
(000)
0
(000)
0
(000)
0
0
Summary total
(000)
(000)
(000)
(000)
Unstamped purchases grand total:
Enter grand total of all unstamped purchases on page 1.
Page
of
Stamped purchases grand total:

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