Form Ct-121s - Wisconsin Combined Cigarette And Use Tax Return

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CT-121S: WISCONSIN COMBINED CIGARETTE
AND USE TAX RETURN
Please print or type.
Read instructions before completing.
2. Federal Employer Identification Number (FEIN)
1. Name of Individual, Partnership, or Corporation
3. Mailing Address – Street or PO Box
4. Social Security Number (SSN)
5. City
6. State
7. Zip
8. Wisconsin County of Business Location
9. Type of Organization (check one)
Indicate Date Incorporated
Other: Describe Below:
Individual
Wisconsin corporation
Partnership
Out-of-state corporation
SECTION A - Schedule of Cigarette Purchases
(5) Invoice
(1) Name and Address of Seller
(2) Date
(3) # of Cartons
(4) Brands
Purchase Price
From Whom Purchased
Purchased
Purchased
Purchased
Totals 
If additional space is needed, attach additional sheets.
$
SECTION B - Computation of Cigarette and Use Taxes
1. Total number of cartons purchased (Section A ,col. (3) total). . . . . . . . . . . . . . .
1
2. Tax rate per carton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
X $25.20
3. Wisconsin cigarette tax (multiply line 1 by line 2) . . . . . . . . . . . . . . . . . . . . . . .
3
$
4. Tax interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
$
$
5. Total Wisconsin cigarette tax and interest (add lines 3 and 4) . . . . . . . . . . . . . .
5
$
6. Total purchase price (Section A, col. (5) total) . . . . . . . . . . . . . . . . . . . . . . . . . .
6
X _____
7. Use tax rate (see Instructions, Table 1) County
7
$
$
8. State, county and stadium use tax (multiply line 6 by line 7) . . . . . . . . . . . . . . .
8
9. Use tax interest (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
$
10. Use tax late filing fee(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
$
11. Total use tax, interest and late filing fee (add lines 8, 9, and 10) . . . . . . . . . . . .
11
$
12. Total Amount Due (add lines 5 and 11) . . . . . . . . . . . PAY WITH RETURN
12
$
I declare under penalties of law that the above information is true, correct and complete to the best of my knowledge and belief.
Your Signature
Date
Your Telephone Number
(
)
CT-121S (R. 2-13)

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