Form Cg-16 Schedule C - Packs Of Cigarettes Not Stamped For Kansas

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS – MISCELLANEOUS SEGMENT
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-5000
Phone: (785) 368-8222
Fax: (785) 291-3968
PACKS OF CIGARETTES NOT STAMPED FOR KANSAS
SCHEDULE C
Please read the instructions on the back of this form.
SOLD TO ___________________ CUSTOMERS*
State
SOLD TO US GOVERNMENT
RETURNED TO MANUFACTURER
Name
Filing Month/Year
Address ___________________________________________
License Number
Number of Cigarette
Returned to
Packs
Manufacturer ONLY
Invoice
Invoice
Date
Number
Sold To / Manufacturer Name
Address
20s
25s
TOTAL THIS PAGE
TOTAL FROM OTHER PAGES
GRAND TOTAL
*One state per sheet.
Page ______ of ______
____________________________________
________________________
________________________
Signature
Title
Date
CG-16
(Rev. 3/10)

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