Schedule A-4 Template - Record Of Snuff Tobacco Products Purchased, Imported, Received, Or Acquired In Connecticut

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Department of Revenue Services
Schedule A-4
State of Connecticut
Excise Taxes Unit
Tobacco Products Tax - Nonresident Distributor
25 Sigourney Street
Record of snuff tobacco products purchased, imported, received, or acquired in Connecticut
Hartford CT 06106
(Rev. 04/05)
Include the total of Schedule A-4 on Line 9 of Form OP-300, Tobacco Products Tax Return. Attach Schedule A-4 to the return.
Attach additional sheets if needed.
Name ________________________________________________
Period Ending ___________________
CT Tax Registration Number __________________________
Address ________________________________________________________________________________________________________________________________________
Weight Each
Total Weight
Date
Invoice Number
Imported To
Brand Name
Quantity
(in ounces)
(Col. 5 x 6)
Column 2
Column 1
Column 3
Column 4
Column 5
Column 6
Column 7
Include this amount on Line 9 of Form OP-300
Total

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