Pa-2 State Tobacco Pact Act Report Form - Illinois Department Of Revenue
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1
2PA-2
State Tobacco P.A.C.T. Act Report
Step 1: Identify your business
Name:
Reporting period: __ __/__ __ __ __
_________________________________________________
(Month/Year)
Address:
License no.: ____________________________
_______________________________________________
Number and street
Federal employer identification number:____-______________
_______________________________________________________
City
State/Province
ZIP
(FEIN)
Phone: (_____)______- ___________ Ext:__________
Country/Territory: ___________________________________
Contact name: ______________________________________
Email address:___________________________________
Step 2: Identify your sales into Illinois
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address
City
State
ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address
City
State
ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address
City
State
ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address
City
State
ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Date: ___ ___ /___ ___ /___ ___ ___ ___
Invoice:_________________________________________
Type:___ Total weight: ______ Quantity:__________
Brand: _____________________________ UPC: ___________________________________________
Wholesale list price: _______________________
Buyer: _____________________________ Address:________________________________________
Retail sales price:$ ________________________
Street address
City
State
ZIP
FEIN: ________________ License #:_________
Deliverer: __________________________ Address: ________________________________________
Phone:(__ __ __)__ __ __ - __ __ __ __
Street address
City
State
ZIP
Step 3: Sign below
Under penalties of perjury, I state that I have examined this report, and, to the best of my knowledge, it is true, correct, and complete. I also
state that such information is taken from the books and records of the business for which this report is filed.
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Owner or officer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
_____________________________
________________________ (____)____-___________
____/____/________
Title:
Preparer’s signature and title (state if individual owner, member of firm, or corporate officer title)
Telephone number (include area code)
Date
PA-2 (R-05/14)
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