Consolidated Monthly Cigarette Return Including Multi-State and Tribal Rates
CIG 50004
Oklahoma Tax Commission
Revised 10-2011
Indicate
2501 North Lincoln Boulevard
Denomination:
Oklahoma City, OK 73194
Taxpayer FEIN
Period of Return
Cigarette License Number
20’s
25’s
____________________________________________________________________ _
_ _ ___________________________________________________________
Firm Name
Contact Person
____________________________________________________________________ _
_ _ ___________________________________________________________
Address
Contact Telephone Number
____________________________________________________________________
City
State
Zip
Indicate Tax
Indicate Tax
Indicate Tax
Indicate Tax
Indicate Tax
Indicate Tax
Indicate Tax
Total
Full Tax Rate
Cigarette Tax Stamps
Jurisdiction
Jurisdiction
Jurisdiction
Jurisdiction
Jurisdiction
Jurisdiction
Jurisdiction
1. On Hand-Beginning of Period
2. Add: Stamps Purchased
3. Total (add lines 1 and 2)
4. Deduct: Stamps Affixed to Packs
5. Deduct: Other Legal Deductions
(attach documentation)
6. Total Deductions (add lines 4 and 5)
7. On Hand-Close of Period
Stamped Cigarettes
8. On Hand-Beginning of Period
9. Add: Packages Stamped
(from line 4)
10._Add: Packages Purchased with
_ _Stamps Affixed
11. Add: Adjustment - Shortage
12. Deduct: Adjustment - Unaccountable
13. Deduct: Sales (attach sales report)
14. On Hand-Close of Period
Unstamped Cigarettes
15. On Hand-Beginning of Period
16. Add: Unstamped Cigarettes Purchased
17. Add: Adjustment - Unaccountable
The return must be filled out completely and in detail and submitted within 10 days
18. Total (add lines 15, 16 and 17)
following the end of the preceding returning period.
19. Deduct: Packages Stamped
(from line 4)
20. Deduct: Other Legal Deductions
(attach documentation)
21. Deduct: Adjustment - Shortage
22. Total Deductions (add lines 19, 20, and 21)
23. On Hand-Close of Period
I, the undersigned wholesaler, distributor, jobber or duly authorized legal representative thereof do declare under the penalties of perjury that this report, including the accompanying schedules which are made a part thereof, is to the best
of my knowledge and belief true and correct.
Signature:_ ________________________________________________________
Official Title: ___________________________________________________
Date: _ _ ______________________
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