Form Ct-114 - Quarterly Report Of Wisconsin Tax-Paid Cigarettes Purchased Page 2

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or write:
Form is located at:
For questions . . .
Excise Tax Section 6-107
• Phone: (608) 266-8970
Wisconsin Department of Revenue
• Fax: (608) 261-7049
PO Box 8900
• E-mail: excise@revenue.wi.gov
Madison WI 53708-8900
Invoice
Purchased From
WISCONSIN
STAMPED
Date
Number
Name
Tax Account Number
Line
Single Cigarettes
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
If additional space is necessary to list all purchases, attach a schedule and enter the subtotal of those
49
purchases on this line.
50
SUBTOTAL - Add lines 17 through 49. Enter here and on line 15 on the front of this form.

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