Form Ct-19 Schedule A - Record Of Unstamped Cigarettes Manufactured, Purchased, Or Otherwise Acquired

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DEPARTMENT OF REVENUE SERVICES
Form CT-19
STATE OF CONNECTICUT
Excise/Public Services Taxes Subdivision
Schedule A
25 Sigourney Street
Hartford CT 06106-5032
Record of Unstamped Cigarettes
Rev. 11/01
Manufactured, Purchased, or Otherwise Acquired
Name of Distributor _____________________________________________ Distributor’s License No. __________________________
Address of Distributor ____________________________________________________________ Month of ____________ 20 ________
The total of Form CT-19, Schedule A , should agree with the amount reported on Line 11 of Form CT-15, Monthly Tax Stamp and Cigarette
Report, Resident Distributor. Forward Form CT-19 to the Department of Revenue Services with Form CT-15.
Date
Supplier
Number of
Received
From Whom Purchased or Acquired
Invoice Number
Cigarettes
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
Total
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
(Continue on reverse side if necessary)

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