DR 1285 (04/30/07)
LICENSED DISTRIBUTOR REPORTING FORM FOR CIGARETTES
COLORADO DEPARTMENT OF REVENUE
SALES OF NON-PARTICIPATING MANUFACTURER BRANDS
EXCISE TAX ACCOUNTING SECTION
18
76
1375 SHERMAN STREET
Provide the following information regarding:
DENVER CO 80261
(303) 205-8211 EXT 6848
• Cigarettes manufactured by a Non-participating Manufacturer that bear a Colorado cigarette tax stamp
FAX (303) 205-8215
• Roll-your-own tobacco manufactured by a Non-participating Manufacturer sold in Colorado
SEE REVERSE FOR INSTRUCTIONS
DUE DATE: 20
TH
DAY OF EACH MONTH FOLLOWING
THE CLOSE OF THE REPORTING MONTH
Reporting Month and Year
Business Name
Business Address
Business Registration Number
Contact Person
Telephone Number
FAX Number
Email Address (required)
A
B
C
D
E
F
Brand Name
Number of ciga-
Number of sticks
Non-participating manufacturer
Name and address of
Name and address
rettes (sticks) sold
converted from
name
the person(s) from
of the first importer of
within Colorado
ounces of roll-your-
and address
whom each brand
foreign manufactured
own tobacco sold
was purchased
brands
within Colorado
I certify that the above-stated information is true and correct.
Signature
Date
Print Name and Title
12
15
Page _______ of ________
Failure to file this report as required may result in the revocation of your cigarette and/or tobacco products license(s) for a period of two years.
Distributor is responsible to notify the Department of any changes to address, telephone number, FAX number or E-mail address.
Under Regulation 39-28-303(2)(c), an email address must be provided to the department for the purposes of the distributor receiving notice of any addition or removal from the
Colorado Certified Brands Directory (CBD). Any subsequent change of the email address shall be submitted to the department by email or in writing within five (5) business days
after the change of the email address. You can notify the department at the address or the fax number at the top of this form or at mastersettlement@spike.dor.state.co.us