Form 612 - Other Tobacco Products (Otp) Storage Warehouse Report

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FORM

OTHER TOBACCO PRODUCTS (OTP)

612

STORAGE WAREHOUSE REPORT

Corporate Name

Location line 1

Report Period (Month & Year)

Location line 2

OTP License #

SW-

This report is a complete and accurate record of all OTP received and delivered in Maryland for the entire report month and is supported by the necessary schedules.

Chewing

RYO Tobacco

Cigars

Pipe Tobacco

Snuff

Other

TOTAL

Tobacco

Total cases on hand first of month

Total cases received during month

Total Line 1 + 2

Total cases on hand end of month

Disposed of or shipped during month

Unaccountable Difference

Total Line 4 + 5 + 6 (Must equal Line

Affidavit

I certify that this report, together with attached schedules, has been examined by me and is, to the best of my knowledge and belief, a true and complete report for the month

stated.

Print name

Title (Owner, Partner of Officer)

Signature

Date

COM/RAD-ATT-612

Rev. 4/13