Form Au-758 - Cigarette Distributor'S Annual List Of Customers

DEPARTMENT OF REVENUE SERVICES

Form AU-758

STATE OF CONNECTICUT

Excise/Public Services Subdivision

Cigarette Distributor’s

25 Sigourney Street

Annual List of Customers

Hartford CT 06106-5032

Rev. 11/01

See Instructions on Reverse Side

Enter Total Number of

Customers From All Pages

Reporting Period _____________________ CT Tax Registration Number _______________________

Cigarette Dealer’s

Customer

Address

License Number

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and,

to the best of my knowledge and belief, it is true, complete, and correct. I understand that the penalty for willfully delivering a false return

to DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other

than the taxpayer is based on all information of which the preparer has any knowledge.

Taxpayer’s Signature

Title

Date

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Parent category: Financial