Form Rev-1048 As - Schedule A-1 Cigarettes Received From Manufacturer During Month

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REV-1048 AS (6-07)
CIGARETTES RECEIVED FROM
MONTH OF
COMMONWEALTH OF PENNSYLVANIA
MANUFACTURER DURING MONTH
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
SCHEDULE A-1
YEAR
PO BOX 280909
HARRISBURG, PA 17128-0909
TELEPHONE: 717-783-9374
TT # 1-800-447-3020 (Services for Taxpayers with
ATTACH TO REV-1030 MONTHLY REPORT
PAGE NO.
Special Hearing and/or Speaking Needs only)
NAME CSA:
ADDRESS (STREET)
(CITY)
(STATE)
(ZIP CODE)
UNSTAMPED CIGARETTES RECEIVED FROM:
(2)
(3)
(4)
(5)
(1)
INVOICE
DATE
NUMBER OF
CREDITS
INVOICE
FOR DEPARTMENT USE
NUMBER
RECEIVED
UNSTAMPED
DATE
CIGARETTES
TOTAL (SCHEDULE “A-1”)
NOTE: PREPARE IN DUPLICATE - MAINTAIN DUPLICATE COPY FOR YOUR RECORDS.

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