Form Cg-19 - Schedule A-1 Damaged Packs Of Cigarettes Or Shortage Of Shipment By Carrier

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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
SCHEDULE A-1
DAMAGED PACKS OF CIGARETTES OR SHORTAGE OF SHIPMENT BY CARRIER
r
r
20s
25s
Name _____________________________
License Number __________________
Filing Month/Year __________________
Number of Cigarette Packs
Invoice
Invoice
Date
Number
Manufacturer Name
Name of Carrier
Address of Carrier
Refused
Shortage
F
0
0
CG-19
TOTALS
(Rev. 6/13)

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