REV-1047 AS (5-05)
SCHEDULE F
MONTH
YEAR
COMMONWEALTH OF PENNSYLVANIA
(SUBMIT WITH REV-1030 – MONTHLY REPORT OF CIGARETTES
DEPARTMENT OF REVENUE
AND CIGARETTE TAX STAMPS)
CIGARETTE TAX UNIT
PO BOX 280909
HARRISBURG, PA 17128-0909
PLEASE PRINT OR TYPE
NAME OF CSA
CSA LICENSE NUMBER
TOTAL NUMBER OF VENDING MACHINES ON
LOCATION IN PA
SECTION 1
SALES OF PENNSYLVANIA STAMPED CIGARETTES
LINE
NUMBER
SALES OF PENNSYLVANIA STAMPED CIGARETTES
TOTAL NUMBER OF CIGARETTES
1
Sales – Through Vending Machines
2
Sales – To Retail Licensees and Consumers
3
Sales – To Wholesale Licensees (list sales to wholesalers below)
4
Total Sales of PA Stamped Cigarettes (Enter this total on REV-1030, section #3, line 11.)
SECTION 2
SALES TO WHOLESALERS
NAME OF WHOLESALER
ADDRESS
CITY
STATE
ZIP CODE
TOTAL NUMBER OF CIGARETTES
Use reverse side to list additional sales to wholesalers.