Form Cg-23 - Kansas Stamped Packs Of Cigarettes Purchased Schedule B

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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
KANSAS STAMPED PACKS OF CIGARETTES PURCHASED
SCHEDULE B
Please read the instructions on the back of this form.
Name
License Number
Address
Filing Month/Year
Number of Cigarette
Invoice
Packs
Invoice
Date
Number
Purchased From
Address
20s
25s
0
0
TOTAL THIS PAGE
TOTAL FROM OTHER PAGES
TOTAL
Page ______ of ______
___________________________________
_____________________________
________________________
Signature
Title
Date
CG-23
(Rev. 6/13)

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