Form Et-60 - Master Settlement Agreement Report
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1
2ET-60
(REV. 1/00)
MASTER SETTLEMENT AGREEMENT REPORT
_______________________________________
Name
_________________________________________
Account Number: ______________________________
DBA
Period: _______________________________________
_____________________________________________
Street
_________________________________________
City
State
Zip
(1)
(2)
(3)
(4)
Number of
Ounces of
cartons of
roll your own
Brand
Manufacturer*
cigarettes
tobacco
*If unknown – report supplier
Report product not covered by MSA. Please refer to our list of brands covered under the MSA.
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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