Form Ct-19a Schedule A-1 - Cigarettes Purchased With Connecticut Decals Or Stamps Already Affixed

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DEPARTMENT OF REVENUE SERVICES
Form CT-19A
STATE OF CONNECTICUT
Excise/Public Services Taxes Subdivision
Schedule A-1
25 Sigourney Street
Hartford CT 06106-5032
Cigarettes Purchased With
Rev. 11/01
Connecticut Decals or Stamps Already Affixed
Name of Distributor _____________________________________________ Distributor’s License No. __________________________
Address of Distributor ____________________________________________________________ Month of ____________ 20 ________
The total of Form CT-19A, Schedule A-1 , should agree with the amount reported on Line 12 of Form CT-15A, Monthly Tax Stamp and
Cigarette Report, Nonresident Distributor. Forward Form CT-19A to the Department of Revenue Services with Form CT-15A.
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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