Form Ct-28 - Schedule F - Sales And Transfers Of Connecticut-Stamped Cigarettes Outside Of Connecticut

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Department of Revenue Services
Form CT-28
PO Box 5031
Hartford CT 06102-5031
Schedule F
(Rev. 06/07)
Sales and Transfers of Connecticut-Stamped
Cigarettes Outside of Connecticut
Name of Distributor __________________________________________ CT Tax Registration Number __________________________
Address of Distributor ____________________________________________________________ Month of ____________ 20 ________
1. Nonresident distributors selling or transferring Connecticut-stamped cigarettes outside of Connecticut must file this schedule.
2. When manufacturers are listed below, use one Schedule F for each manufacturer and file in duplicate. All non-manufacturers may
be listed on one Schedule F and no duplicate copies are required.
3. The total of Form CT-28, Schedule F, should agree with the amount reported on Line 17 of Form CT-15A, Monthly Tax Stamp and
Cigarette Report, Nonresident Distributor. Forward Form CT-28 to the Department of Revenue Services with Form CT-15A.
Number of
Date
Name and Address to Whom Sold, Transferred, or Returned
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
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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