Form Pa-1 - State Cigarette P.a.c.t. Act Report

PA- 1

State Cigarette P.A.C.T. Act Report

Step 1: Identify your business

Name:

Reporting period: __ __/__ __ __ __

_________________________________________________

(Month/Year)

Address:

License no.: ____________________________

_______________________________________________

Number and street

Federal Employer Identification Number:____-______________

_______________________________________________________

City State/Province ZIP

(FEIN)

Country/Territory: ___________________________________

Phone: (_____)______- ___________ Ext:__________

Contact name: _ _____________________________________

Email address:___________________________________

Step 2: Identify your sales into ____________________

Identify the state

Date: ___ ___ /___ ___ /___ ___ ___ ___

Invoice:_________________________________________

Cigarettes (sticks):________________________

Brand:_____________________________ UPC: ___________________________________________

Sale price: $_______________________________

Buyer: _____________________________ Address:________________________________________

FEIN: ________________ License #:___________

Street address City State ZIP

Deliverer: __________________________ Address:________________________________________

Phone:(__ __ __)__ __ __ - __ __ __ __

Street address City State ZIP

Date: ___ ___ /___ ___ /___ ___ ___ ___

Invoice:_________________________________________

Cigarettes (sticks):________________________

Brand:_____________________________ UPC: ___________________________________________

Sale price: $_______________________________

Buyer: _____________________________ Address:________________________________________

FEIN: ________________ License #:___________

Street address City State ZIP

Deliverer: __________________________ Address:________________________________________

Phone:(__ __ __)__ __ __ - __ __ __ __

Street address City State ZIP

Date: ___ ___ /___ ___ /___ ___ ___ ___

Invoice:_________________________________________

Cigarettes (sticks):________________________

Brand:_____________________________ UPC: ___________________________________________

Sale price: $_______________________________

Buyer: _____________________________ Address:________________________________________

FEIN: ________________ License #:___________

Street address City State ZIP

Deliverer: __________________________ Address:________________________________________

Phone:(__ __ __)__ __ __ - __ __ __ __

Street address City State ZIP

Date: ___ ___ /___ ___ /___ ___ ___ ___

Invoice:_________________________________________

Cigarettes (sticks):________________________

Brand:_____________________________ UPC: ___________________________________________

Sale price: $_______________________________

Buyer: _____________________________ Address:________________________________________

FEIN: ________________ License #:___________

Street address City State ZIP

Deliverer: __________________________ Address:________________________________________

Phone:(__ __ __)__ __ __ - __ __ __ __

Street address City State ZIP

Date: ___ ___ /___ ___ /___ ___ ___ ___

Invoice:_________________________________________

Cigarettes (sticks):________________________

Brand:_____________________________ UPC: ___________________________________________

Sale price: $_______________________________

Buyer: _____________________________ Address:________________________________________

FEIN: ________________ License #:___________

Street address City State ZIP

Deliverer: __________________________ Address:________________________________________

Phone:(__ __ __)__ __ __ - __ __ __ __

Street address City State ZIP

Step 3: Sign below

Under penalties of perjury, I state that I have examined this report, and, to the best of my knowledge, it is true, correct, and complete. I also

state that such information is taken from the books and records of the business for which this report is filed.

_____________________________

________________________ (____)____-___________

____/____/________

Title:

Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title) Telephone number (include area code) Date

_____________________________

________________________ (____)____-___________

____/____/________

Title:

Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title) Telephone number (include area code) Date

PA-1 (N-11/10)