Form Cg-30 - Sales Of Non-Participating Manufacturer (Npm) Cigarettes In Kansas Schedule Msa-Cig-1

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KANSAS DEPARTMENT OF REVENUE
MISCELLANEOUS TAX – CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66612-1588
Web site:
Email: miscellaneous.tax@kdor.ks.gov
Phone: (785) 368-8222
Fax: (785) 291-3968
SALES OF NON-PARTICIPATING MANUFACTURER (NPM) CIGARETTES IN KANSAS
SCHEDULE MSA-CIG-1
Check One:
Original Report
Amended Report
Business Name ____________________________________________________________
License Number ______________________________
Address __________________________________________________________________
Filing Month/Year _____________________________
A
B
C
D
E
F
Number of Packs Stamped
From Whom Brand was Purchased
First Importer of Foreign
Non-Participating Manufacturer
NPM Cigarette
and Sold in Kansas
(If Different from Manufacturer)
Manufactured Brands
Brand Family Name
Full Name & Address
20s
25s
Full Name & Address
Full Name & Address
Visit for a current list of manufacturers and brands certified for sale in Kansas.
I certify that my business did not stamp and sell NPM cigarettes in Kansas during the filing month (Check if applicable).
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Signature ________________________________________________________
Executed on (Date) ________________________
Print Name & Title _________________________________________________
Page ______ of ______ (Use additional schedules if necessary)
CG-30
(Rev. 6/13)

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