Form Tt-12 - Virginia Application For Tobacco Tax Credit Certificate Page 2
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1
2
3Schedule A
Additional Information Required For Bad Debt Credit
Form TT-12
• See the reverse side for instructions.
Stamping Agent Name
Permit Number
Contact Person
Phone Number
(
)
I. Invoice Information
a. Customer Name
b. Invoice Number
c. Invoice Amount
d. Invoice Date
e. Delivery Date
f. Number of Cigarette Cartons
g. Amount of Credit Claimed ($3.00 times number of cartons)
h. Were any partial payments received on this invoice?
i. Amount Received
j. Date Received
Yes
No
If Yes, please complete i and j.
II. Collection Information - Must be verifiable.
a. Date
b. Method Of Contact
c. Results
1st Collection Contact
Phone
Mail
d. Date
e. Method Of Contact
f. Results
2nd Collection Contact
Phone
Mail
g. Date Sent
h. Date Certified Mail Received By Customer
3rd Collection Contact - “Demand for Payment” sent by Certified Mail
i. Sent to a Collection Agency?
j. Date Sent
Yes
No
If Yes, please complete j through n.
k. Name of Collection Agency
l. Address of Collection Agency
m. Dates Customer Was Contacted
n. Results
III. Write-Off Information
a. Date Written-Off
b. Journal Entry Number
IV. Other Information
a. Date of Most Recent Invoice to This Customer
b. Amount of Most Recent Invoice to This Customer
VA Form TT-12, Schedule A
Rev. 8/06
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