TT-104S: WISCONSIN TOBACCO PRODUCTS
AND USE TAX RETURN
Please print or type.
Read instructions before completing.
1. Name of Individual, Partnership, or Corporation
2. Federal Employer Identification Number (FEIN)
3. Mailing Address – Street or PO Box
4. Social Security Number (SSN)
5. City
8. Wisconsin County of Business Location
6. State
7. Zip
9. Type of Organization (check one)
Indicate Date Incorporated
Other: Describe Below:
Individual
Wisconsin corporation
Partnership
Out-of-state corporation
SECTION A - Schedule of Tobacco Products Purchases
(5) Invoice
(1) Name and Address of Seller
(3) Invoice
(4) Brands
(2) Date
Purchase Price
From Whom Purchased
Purchased
Purchased
Number
If additional space is needed, attach additional sheets.
Total è
$
SECTION B - Computation of Tobacco Products and Use Taxes
1 Total cost of tobacco products purchased, excluding moist snuff and cigars
$
1
2 Tobacco products tax rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.71
2
3 Tobacco products tax (multiply line 1 by line 2) . . . . . . . . . . . . . . . . . . . . . . .
3
$
4 Total cost of moist snuff purchased (100% tax rate) . . . . . . . . . . . . . . . . . . .
4
$
5 Total cost of cigars purchased for $0.50 or less . . . . . . . . . . . . . . . . . . . . . .
5
$
6 Cigar tax (line 5 x .71) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
$
7 Number of single cigars purchased for more than $0.50 . . . . . . . . . . . . . . . .
7
8 Cigar tax (line 7 x .50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
$
9 Tobacco products, moist snuff, and cigar tax (add lines 3, 4, 6, and 8) . . . . .
9
$
10 Interest on tobacco products, moist snuff, and cigars (see instructions) . . . . 10
$
11 Amount subject to use tax (Section A, col. (5) total) . . . . . . . . . . . . . . . . . . . 11
$
12 Use tax rate (see Instructions, Table 1) County
12
x
13 State, county, and stadium use tax (multiply line 11 by line 12) . . . . . . . . . . . 13
$
14 Interest on use tax (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
$
15 Late filing fee on use tax (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 15
$
16 Total use tax, interest and late filing fee (add lines 13, 14, and 15) . . . . . . . . 16
$
17 Total Amount Due (add lines 9, 10, and 16) . . . . . . . . . . . . . . . . . . . . . . . . 17
$
I declare under penalties of law that the above information is true, correct, and complete to the best of my knowledge and belief.
Signature
Date
Telephone Number
(
)
TT-104S (R. 2-13)