Dbpr Form Ab&t 4000a-205-1 - Taxable Cigarette Wholesale Dealer'S Monthly Report
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1DBPR Form AB&T
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
4000A-205-1
DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO
Rev. 12/03
1940 NORTH MONROE STREET • TALLAHASSEE, FL 32399-1022
TAXABLE CIGARETTE WHOLESALE DEALER'S
MONTHLY REPORT
Prepare in TRIPLICATE. Submit ORIGINAL and FIRST COPY to the AUDITING DISTRICT OFFICE of the DIVISION OF ALCOHOLIC BEVERAGES
AND TOBACCO. SECOND COPY is to be retained by the licensee. This report and payment must be filed in accordance with the provisions of
Chapter 561, Florida Statutes, on or before the tenth day of the month following the month being reported. Make remittances payable to the
"Division of Alcoholic Beverages and Tobacco".
Permit Name
Phone No. (
)
Permit No.
Address
City
State
Zip
Month Reported
20
Reporting Period
through
This report is true and correct to the best of my knowledge and belief and is submitted under penalty of perjury.
Typed or Printed Name
Authorized Signature
STAMP PURCHASES
C.O.D. (CASH)
CHARGE (DEFERRED)
Invoice/Receipt
10s
20s
25s
Date
Net Tax
Number
@ $.1695
@ $.339
@ $.42375
TOTAL STAMPS
(Transfer to line 2 below)
Total Purchases Charged This Month
(Add NET TAX DUE column if Deferred Purchases Method)
Less: Applicable DAB&T Approved Credit(s) #
#
#
Net Remittance Due With This Report
40823
10s
20s
25s
STAMP USAGE
1
Beginning Balance on Hand
(Ending balance of previous month)
2
Total Purchased
(From TOTAL STAMPS line above)
3
Total Available For Use
(Add line 1 and line 2)
4
Total Used
(Number of stamps placed on packages during month)
5
Total Lost or Destroyed
(Attach approved documentation)
Total Accounted For
6
(Add line 4 and line 5)
7
Ending Balance on Hand
(Line 3 less line 6)
DAB&T USE ONLY
Report Receipt
In'ls
Payment Verification
In'ls
Field Review
In'ls
Central Processing
In'ls
Postmark Date
Receipt Number
Initial Review Date
Initial Receipt Date
Delivery Date
Payment Date
Amended Date
Completed Date
Delinquent Action
Excise Tax Paid
Amended Amount
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