Form Dr 1285 - Licensed Distributor Reporting Form For Cigarettes Sales Of Non-Participating Manufacturer Brands

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DR 1285 (09/11/13)

Licensed Distributor Reporting Form for Cigarettes Sales

COLORADO DEPARTMENT OF REVENUE

Excise Tax Accounting Section, Room 237

of Non-Participating Manufacturer Brands

PO Box 17087

Denver, CO 80217-0087

(303) 205-8211 Ext 6848

Fax (303) 205-8204

Identifying Information

Due Date: 20th of Each Month

Reporting Month and Year

Business Name

Business Address

Colorado Account Number

Contact Person

Phone Number

FAX Number

Email Address (required)

Tax Paid Sales and Tax Exempt Sales — Provide the following information regarding:

•

Cigarettes manufactured by a Non-Participating Manufacturer that bear a Colorado cigarette tax stamp

•

Tax paid Non-Participating Manufacturer Roll-Your-Own Tobacco sold in Colorado

Brand Name

Number of

Number of ounces

Number of sticks

Non-participating

Name and address

If Product is Tax

cigarettes (sticks)

(oz.) of roll-your-own

converted from

manufacturer name

from which each

Exempt, Check

sold within

(RYO)

ounces of RYO

and address

brand was

Box Below

Colorado

(ounces ÷ .09)

purchased

I certify that the above-stated information is true and correct.

Signature

Date

Print Name and Title

(MM/DD/YY)

Page ____of____

Failure to file this report as required may result in the revocation of your cigarette and/or tobacco products license(s) for a period of two years.

Distributor is responsible to notify the Department of any changes to address, telephone number, FAX number or E-mail address.

Under Regulation 39-28-303(2)(c), an E-mail address must be provided to the department for the purposes of the distributor receiving notice of any addition or removal from the

Colorado Certified Brands Directory (CBD). Any subsequent change of the email address shall be submitted to the department by email or in writing within five (5) business days after

the change of the email address. You can notify the department at the address or the fax number at the top of this form or at dor_master_settlement@state.co.us