Form 528 - Report Of Cigarettes Made By Nonparticipating Manufacturers Imported Into Alaska Per As 45.53

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Alaska Department of Revenue

528

Report of Cigarettes made by Nonparticipating Manufacturers Imported into Alaska per AS 45.53

Due Date: This report is due with the monthly tax return during which the cigarettes or “roll-your-own” were imported.

Name of Licensee

License Number

Period Ending (Month/Year)

Federal

EIN or

SSN

Report only when you import products made by manufacturers not listed below. A current list can be found on our web site at

Instructions: The information on this report is required to comply with the Master Settlement Agreement (“Agreement”) entered into between certain tobacco manufacturers (“Participating Manufacturers”)

and the State of Alaska. As part of the Agreement, information about cigarettes and loose-leaf tobacco suitable for making cigarettes (“roll-your-own”), made by manufacturers who did not sign the Agreement

(“Nonparticipating Manufacturers”), and imported into Alaska, must be compiled by the State. A list of Participating Manufacturers appears on the bottom of this form and can be accessed through our web

site. If you import cigarettes and/or roll-your-own tobacco from a manufacturer, either directly or through a distributor, which is not a participating manufacturer, complete this form and attach it to your monthly

cigarette and tobacco products excise tax return, Form 0405-522.

Ounces of

Cigarette or

Number of

roll-your-own

Nonparticipating Manufacturer’s Name

RYO Brand

Address

City

State

Zip

Country