BOE-501-CD (S1B) REV. 11 (4-13)
TAX VALUE
PART 2 - STAMP ACCOUNT FOR CALENDAR MONTH
PRIOR TO DISCOUNT
1a.
1a. Tax value of unaffixed stamp inventory
1. Inventory first of month
(should agree with part 2,
1b. Tax value of stamps affixed to packages
1b.
line 5 of previous
month's report)
1c. Total (add lines 1a and 1b)
$
1c.
2. Tax value of stamps purchased
2.
$
3. Tax value on tax-paid cigarette receipts
3.
$
4. Total tax value to account for (add lines 1c through 3)
4.
$
5a. Tax value of unaffixed stamp inventory
5a.
5. Inventory end of month
5b. Tax value of stamps affixed to packages
5b.
5c. Total (add lines 5a and 5b)
5c.
$
6.
Tax value of stamps used (subtract line 5c from line 4)
6.
$
7. Unusable stamps for which claim has been filed
7.
$
8. Tax value of stamps affixed to packages sold (subtract line 7 from line 6, also enter on part 1, line 12) 8.
$
CERTIFICATION
I hereby consent to disclose and authorize the BOE to release, as necessary, certain otherwise confidential transaction
information regarding quantities, invoice numbers, bills of lading, locations, dates, method of delivery, or any other applicable
information to any person identified by me in this tax form as being involved in a reported transaction for the sole purpose of
verifying the accuracy of the reportable product transaction information concerning my transactions with such person as
reported in this tax form.
EMAIL ADDRESS
I hereby certify that this report, including any accompanying schedules and statements, has been
examined by me and to the best of my knowledge and belief is a true, correct, and complete report.
SIGNATURE
PRINT NAME AND TITLE
TELEPHONE
DATE
(
)
This report must be signed. Make a copy of this document and the accompanying schedules for your records.
CLEAR
PRINT