Form 2009 - South Carolina Oglala Sioux Tribe (Pine Ridge Reservation) Monthly Other Tobacco Product Sales Report

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SD EForm - 2009
V1
Complete and use the button at the end to print for mailing.
OGLALA SIOUX TRIBE (PINE RIDGE RESERVATION)
MONTHLY OTHER TOBACCO PRODUCT SALES REPORT
Mail to: Department of Revenue, Special Tax Division, 445 E Capitol Ave Pierre, SD 57501-3100
Other tobacco products sold in the month of _________________________________, 20_____
Licensed tobacco distributors are required to file a monthly report of tobacco products (other than cigarettes)
sold to retailers located on the Pine Ridge Indian Reservation.
The report shall show the dollar amount of OTP sales to retailers within the following:
Bennett County:
Allen Store, Allen, SD
$
Shannon County:
Batesland Town
$
Kyle, SD
$
Manderson, SD
$
Oglala, SD
$
Pine Ridge, SD
$
Porcupine, SD
$
Sharps Corner, SD
$
Wounded Knee, SD
$
Jackson County:
Wanblee, SD
$
Long Valley, SD
$
TOTAL AMOUNT:
$
0.00
I, the undersigned, certify that this return is an accurate and true report of all other tobacco products sold on the Pine Ridge
Reservation during the month indicated above.
Signed: ___________________________________________
Title: _____________________________________________
Company: _________________________________________
Address: __________________________________________
NOTE: This report is due prior to the 10th of each month listing all sales for the previous month and mailed to the address listed above.
PRINT FOR MAILING
CLEAR FORM

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