Form Cg-15 - Unstamped Cigarette Packs Received Per Manufacturer And Kansas Stamps Affixed To Packs (Out-Of-State Distributors) Page 2
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1
2Unstamped Cigarette Packs Received Per Manufacturer and
Kansas Stamps Affixed To Packs (Out-Of-State Distributors)
KANSAS DISTRIBUTORS
1. Check the box next to Unstamped Packs Received Per Manufacturer.
2. Check the appropriate box for 20s or 25s. Use a separate sheet for each.
3. Enter your company’s name and license number.
4. Enter the name of the manufacturer or distributor you received the cigarettes from. If the original manufacturer is a NPM,
you must complete a Schedule MSA. Please see for the PM and NPM lists.
5. Circle D if the company you purchased from is a Distributor or M if the company you purchased from is a Manufacturer.
6. Enter the Filing month and year.
7. Enter the date of the invoice from the manufacturer or distributor.
8. Enter the invoice number from the manufacturer or distributor.
9. Enter the gross amount of cigarette packs you received under the invoice.
10. Enter the number of packs that you refused or were shorted under the invoice. You must attach a Schedule A-1.
11. Enter the net amount of cigarette packs you received under the invoice.
12. Enter each invoice you receive from the named manufacturer or distributor for the reporting month as above. Use
another sheet if needed.
13. Enter the name of the original manufacturer if you purchased the cigarettes from another distributor.
14. Enter the page number if you use more than one page per manufacturer or distributor.
15. Sign the form attesting that the figures on this form are true and correct.
16. Enter your title with your company.
17. Enter your phone number.
OUT-OF-STATE DISTRIBUTORS
1. Check the box next to Kansas Stamped Cigarettes Sold.
2. Check the appropriate box for 20s or 25s. Use a separate sheet for each.
3. Enter you company’s name and license number.
4. Enter the name of the manufacturer or distributor you received the cigarettes from. If the original manufacturer is a NPM, you
must complete a Schedule MSA. Please see for the PM and NPM lists.
5. Circle D if the company you purchased from is a Distributor or M if the company you purchased from is a Manufacturer.
6. Enter the Filing month and year.
7. Enter the number of cigarette packs that you stamped for Kansas from the manufacturer or distributor named above in the
Net Amount of Packs Received column.
8. Enter the page number if you use more than one page per manufacturer or distributor.
9. Sign the form attesting that the figures on this form are true and correct.
10. Enter your title with your company.
11. Enter your phone number.
CIGARETTES IMPORTED INTO THE UNITED STATES
Per K.S.A. 79-3395, you must file the following information if you import cigarettes into the United States.
1. A copy of the permit issued pursuant to the internal revenue code, 26 U.S.C. 5713, to the person importing such cigarettes into
the United States allowing such person to import such cigarettes.
2. A copy of the customs form containing, with respect to such cigarettes, the internal revenue tax information required by the U.S.
bureau of alcohol, tobacco and firearms.
3. A statement signed by such person under penalty of perjury, which shall be treated as confidential, identifying the brands and
brand styles and the quantity of each, who supplied the cigarettes and the person or persons, if any, to whom such cigarettes
have been conveyed for resale.
4. A statement, signed by an officer of the manufacturer or importer under penalty of perjury, certifying that the manufacturer or
importer under penalty of perjury, certifying that the manufacturer or importer has complied with (1) the package health warning
and ingredient reporting requirements of the federal cigarette labeling and advertising act, 15 U.S.C 1333 and 1335a, with
respect to such cigarettes; and (2) the provisions of K.S.A. 50-6a01 et seq., and amendments thereto, including a statement
indicating whether the manufacturer is, or is not, a participating tobacco product manufacturer within the meaning of K.S.A. 50
6a01 et seq., and amendments thereto.
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