Form Cg-15 - Unstamped Cigarette Packs Received Per Manufacturer And Kansas Stamps Affixed To Packs (Out-Of-State Distributors)

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS – MISCELLANEOUS SEGMENT
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-5000
Phone: (785) 368-8222
Fax: (785) 291-3968
UNSTAMPED CIGARETTE PACKS RECEIVED PER MANUFACTURER
KANSAS STAMPED CIGARETTES PACKS SOLD (OUT OF STATE DISTRIBUTORS)
20s
25s
SCHEDULE A
Please read the instructions on the back of this form.
Company Name ____________________________________
License Number __________________
Received from _____________________________________ D M *
Filing Month / Year _______________
In-State Distributors ONLY
If Purchased from
Gross amount of
Refused or
Net Amount of Packs
Invoice
Invoice
Another Distributor Name
Packs
Shortage**
Received
of Original Manufacturer
Date
Number
TOTAL THIS PAGE
TOTAL OTHER PAGES
TOTAL
* Circle one.
**If an amount is entered in the Refused or Shortage Column, Schedule A-1 must be completed and attached.
Page ________ of ________
___________________________________
__________________________
_______________________
Signature
Title
Phone Number
CG-15
(Rev. 3/10)

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