Monthly Report Of Cigarettes Stamped And Roll Your Own Tobacco Purchased {CT-19}

State Form 51482 (R5 / 6-14) CT-19 Form Indiana Department of Revenue Monthly Report of Cigarettes Stamped and Roll-Your-Own Tobacco Purchased This report must be postmarked on or before the 15 day of the month following the reporting month. th Amended No Activity Month/Year of Report Distributor Name Taxpayer Identification Number License Number Instructions: Enter your distributor name and license number and the period for which you are reporting. List the brand family, the number of cigarettes (in sticks) that were stamped for the period per brand, the number of ounces of roll-your-own-tobacco you purchased per brand, and the conversion of the roll-your-own-tobacco to units. List the name, address, city, and state from whom the cigarettes and roll-your-own tobacco were purchased. The taxpayer or agent completing the form must list their name, title, email, phone, and the date the form was completed. Note: The term "roll-your-own tobacco" is any tobacco which, because of its appearance, type, packaging, or labeling, is suitable for use and likely to be offered to, or purchased by, consumers as tobacco for making cigarettes. Nine-hundredths (0.09) of an ounce of "roll-your-own" tobacco constitutes one (1) individual cigarette or unit. Cigarettes/RYO Brand Family Quantity Stamped (Sticks) Roll-Your-Own Roll-Your-Own Tobacco Tobacco Units Ounces (units = ounces/.09) Name Purchased From Address City State ZIP Code I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and statements, is true, correct, and complete to the best of my knowledge and belief. Signature of Taxpayer or Agent Title Telephone Number Printed Name of Taxpayer or Agent Email Date A copy of the completed form must be sent to each agency below: (forms can be sent via postal mail, email, or fax) Indiana Department of Revenue Fax: 317-615-2691 PO Box 901 Email: INCigTax@dor.in.gov Indianapolis, IN 46206-0901 Office of Indiana Attorney General Attn: Tobacco Enforcement IGC-South 5th Floor 302 W. Washington St. Indianapolis, IN 46204 Fax: 317-232-7979 Email: tobacco@atg.in.gov American LegalNet, Inc. www.FormsWorkFlow.com