Form Tob 50003 - Monthly Return Of Tobacco Products Sold To Federally Recognized Indian Tribes Or Nations

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TOB 50003
Revised 10-2012
Monthly Return of Tobacco Products Sold to
Federally Recognized Indian Tribes or Nations
Oklahoma Tax Commission
2501 North Lincoln Boulevard
Oklahoma City, OK 73194
Taxpayer FEIN/SSN
Month of Return
Tobacco License Number
________________________________________________________
_______________________________________________
Firm Name
Contact Person
________________________________________________________
_______________________________________________
Address
Contact Telephone Number
________________________________________________________
City
State
Zip
Compact
Smoking Tobacco
Chewing Tobacco
Little Cigars
Class “C” Cigars
Full Rate
State/Tribal Border
New Compact
Exception Rate
State/Tribal
Texas Border
No Tax Rate
Unity Rate
1. Total 2004 and Prior Tax ........................................................................ __________________________
2. Total 2005 Tax ........................................................................................ __________________________
3. Total Tribal Trust Fund Tax ..................................................................... __________________________
4. Subtotal ................................................................................................. __________________________
5. 2% Discount (if timely filed) ................................................................... __________________________
6. Total Tax ................................................................................................. __________________________
7. Interest (for interest, add 0.04% of line 6 for each day of late filing) .. + __________________________
8. Penalty (for penalty, add 10% of line 6 for filing late).......................... + __________________________
9. Total Tribal Tax Due (add lines 6, 7 and 8) ......................................... __________________________
The undersigned wholesaler, distributor, jobber or duly authorized legal representative thereof, do declare under the penalties of perjury that
this return, including the accompanying schedules which are made a part hereof, is to the best of my knowledge and belief, true and correct.
Official Title
Signature
Date

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