SD EForm -
1973
V4
HELP
Complete and use the button at the end to print for mailing.
Other Tobacco Products Monthly Tax Return
for Distributors & Wholesalers
Department of
R
evenue
This report must be filed with the Department of Revenue by the 15th day of the month following
the period for which this report is filed.
B
u
i s
e n
s s
N
a
m
e
T
b o
c a
o c
D
s i
/ . t
W
h
. l o
L
c i
n e
e s
#
A
d d
e r
s s
F
E
N I
S /
S
N
. o
C
y t i
S
a t
e t
Z
p i
M
n o
/ h t
e Y
r a
C
n o
a t
t c
P
o h
e n
#
A. Residents - enter wholesale purchase price of tobacco products.
Non-residents - enter wholesale purchase price of tobacco products shipped to
South Dakota recipients ........................................................................................... $ _________________________
B. Deductions
1) returns to supplier ......................................................................................... $ _________________________
2) shipped out of the state (Residents only - attach list of out-of-state
customers) .................................................................................................... $ _________________________
0.00
C. Taxable value of Tobacco Products (line A minus B1 & B2) .................................. $ _________________________
0.00
D. Tax @ 35% (line C times .35).................................................................................. $ _________________________
E. Interest for late payment .......................................................................................... $ _________________________
F. Penalty for late filing ............................................................................................... $ _________________________
PLEASE PAY THIS AMOUNT (lines D + E + F) ......................
0.00
$ _________________________
I
v n
i o
e c
D
a
e t
I
v n
i o
e c
N
u
m
b
r e
n I
s -
a t
e t
c i l
n e
e s
s e
-
P
r u
h c
s a
d e
f
o r
m
W
o h
e l
a s
e l
p
u
c r
a h
e s
p
i r
e c
O
u
- t
f o
s -
a t
e t
c i l
n e
e s
s e
-
S
o
d l
o t
C
o
n
n i t
e u
o
n
e n
t x
a p
e g
r o
a
a t t
h c
r p
n i
o t
t u
T
o
l a t
P
i r
e c
f o
T
o
b
c a
o c
P
o r
d
c u
s t
0.00
I hereby certify that, to the best of my knowledge and belief, this report is true, correct and complete and that no
tobacco products have been sold or disposed of contrary to the provisions of SDCL 10-50.
Please remit form and payment to
Division of Special Taxes
445 E. Capitol Avenue
Pierre, SD 57501
Phone: 605-773-3311
Signature of Owner or Manager
Date
Fax: 605-773-6729
1
2
Form M-19 - Cigarette And Tobacco Products Monthly Tax Return Form - State Of Hawaii - Department Of Taxation
Financial
Form 04-522 - Cigarette And Tobacco Products Monthly Tax Return, Supporting Schedule Of Transactions - 2000
Financial
