Form Msa 60 - Master Settlement Agreement Report
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2MSA 60
Rev. 3/08
•
P.O. Box 530
Columbus, OH 43216-0530
Master Settlement Agreement Report
Name
Account number
DBA
Period
Street
City
State
ZIP
(3)
(4)
Total
Total OUNCES
Brand ID
CARTONS of
of roll-your-own
(internal
(1)
cigarettes SOLD
tobacco SOLD
(2)
use only)
Brand
Manufacturer
in Ohio
in Ohio
Report ONLY products not covered by the Master
Settlement Agreement (MSA). Please refer to the attorney general’s Web
site ( ) for the list of brands covered under the MSA. Products not covered by the MSA are designated NPM
(non-participating manufacturers) on the attorney general’s Web site.
I declare under the penalties of perjury that this report (including any accompanying schedules and statements) has been examined
by me and to the best of my knowledge and belief is a true, correct and complete report.
Signature
Date
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