Form Ct401-I - Nonresident Distributors Cigarette Inventory
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1CT401-I
Attachment #4
Nonresident Distributors
Cigarette Inventory
Check if certified inventory:
Licensee
Address
Minnesota Tax ID Number
Period of Return (mo/yr)
# of Stamps
Value of Stamps
1 Minnesota stamps
Regular 20s
x $ 3.614
=
Regular 25s
x
4.5175
=
Native American 20s
x
3.614
=
Native American 25s
x
4.5175
=
Total value of Minnesota stamps (also enter on CT401-R, line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $
Minnesota Stamped Cigarettes (including unsaleable)
# of Cartons
Value of Cigarettes
Regular
2 a. Non-fee brands (200s)
x $36.14
= 2a
= 2b
b. Fee brands (200s)
x
36.14
Total cartons
Total value . . . . . . . . . . . . . . . 2 $
3 a. Non-fee brands (250s)
x $45.175
= 3a
b. Fee brands (250s)
x
45.175
= 3b
Total cartons
Total value . . . . . . . . . . . . . . . 3 $
Native American
4 a. Non-fee brands (200s)
= 4a
x $36.14
b. Fee brands (200s)
x
36.14
= 4b
Total cartons
Total value . . . . . . . . . . . . . . . 4 $
5 a. Non-fee brands (250s)
x $45.175
= 5a
= 5b
b. Fee brands (250s)
x
45.175
Total cartons
Total value . . . . . . . . . . . . . . . 5 $
Value of non-fee brands (add lines 2a, 3a, 4a and 5a; also enter on CT401-R, line 10B) . . . . . . . . . . . . . . . . . 6 $
6
Value of fee brands (add lines 2b, 3b, 4b and 5b; also enter on CT401-R, line 10C) . . . . . . . . . . . . . . . . . . . . . 7 $
7
8
Total value of Minnesota stamped cigarettes (add lines 6 and 7; also enter on CT401-R, line 10D) . . . . . . . . 8 $
Must be signed and certified by an officer or owner.
I certify that the above inventory has been examined by me and is true and correct to the best of my knowledge.
Authorized Signature of Officer or Owner
Title
Date
(Rev. 1/18)
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