Form Tb-42c - Schedule 3 - Monthly Report Of Roll-Your-Own-Tobacco Products

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS – MISCELLANEOUS SEGMENT
915 SW HARRISON ST.
TOPEKA, KANSAS 66612-1588
Web site:
Email: miscellaneous.tax@kdor.ks.gov
Phone: (785) 368-8222
Fax: (785) 291-3968
SCHEDULE 3
MONTHLY REPORT OF ROLL-YOUR-OWN-TOBACCO PRODUCTS
Distributor’s Name __________________________________
License Number __________________
License Number __________________
Address ____________________________________________
Filing Month/Year
Filing Month/Year ________________
*Distributor’s/Manufacturer’s Name ______________________________________________________
Original Manufacturer If
Invoice
Invoice
Purchases From Another
Quantity
Manufacturer’s Net
Date
Number
Distributor
Brand Name**
(Ounces)
Invoice Price
PAGE TOTAL
0
0.00
GRAND TOTAL
**Attach one invoice from each Non-Participating Manufacturer.
TB-42C
(Rev. 8/11)

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