Form Ct-19 - Schedule A - Record Of Unstamped Cigarettes Manufactured, Purchased, Or Otherwise Acquired

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Department of Revenue Services
Form CT-19
PO Box 5031
Hartford CT 06102-5031
Schedule A
(Rev. 10/05)
Record of Unstamped Cigarettes
Manufactured, Purchased, or Otherwise Acquired
Name of Distributor __________________________________________ CT Tax Registration Number __________________________
Address of Distributor ____________________________________________________________ Month of ____________ 20 ________
The total of Form CT-19, Schedule A, should agree with the amount reported on Line 11 of Form CT-15, Monthly Tax Stamp and Cigarette
Report, Resident Distributor. Forward Form CT-19 to the Department of Revenue Services (DRS) with Form CT-15.
Date
Supplier
Number of
Received
From Whom Purchased or Acquired
Invoice Number
Cigarettes
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
Total
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
(Continue on reverse side if necessary)

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