Form Rev 82 2109-2 - Non-Participating Manufacturer Supplemental Reporting Form
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2Washington State
Department of Revenue
Non-Participating Manufacturer
Special Programs Division
PO Box 47477
Supplemental Reporting Form and Instructions
Olympia, Washington 98504-7477
Instructions for Completing Reverse Side
As part of the Master Settlement Agreement between
certain cigarette manufacturers and the state of
Column A:
Washington, the Department of Revenue is required to
compile information about cigarettes and roll-your-own
Enter the number of individual cigarettes sold in
tobacco sold in Washington. Please refer to
Washington in packages bearing the excise tax stamp
Chapter 70.157 RCW and WAC 458-20-264.
of this state. List only cigarettes contained in
packages to which you affixed the excise tax stamp of
This supplemental reporting form is to be used only for
Washington. Include complimentary cigarettes that
reporting sales of cigarettes to Indian Tribes with a
are given away unstamped, if you are liable for the
Cigarette Tax Contract; RCW 43.06.450.
payment of the tax on those cigarettes. Do not list
cigarettes that were purchased with the tax stamp
Complete this form and submit it monthly if you are a
already affixed
cigarette wholesaler or if you are a tobacco products
distributor.
Column B:
Definitions
Enter number of ounces of roll-your-own tobacco sold
in Washington. List only roll-your-own tobacco where
"Cigarette" means any product that contains nicotine, is
you were liable for Washington’s tobacco products
intended to be burned or heated under ordinary
tax.
conditions of use, and consists of or contains (i) any roll
of tobacco wrapped in paper or in any substance not
Column C:
containing tobacco; or (ii) tobacco, in any form, that is
Enter the full brand name of the product sold (do not
functional in the product, which, because of its
abbreviate). Do not break down into sub-categories,
appearance, the type of tobacco used in the filler, or its
such as regular, menthol, light, etc. For example, for
packaging and labeling, is likely to be offered to, or
a cigarette named “Alpha Bravo Gold Menthol Lights”,
purchased by, consumers as a cigarette; or (iii) any roll of
report only “Alpha Bravo Gold”. Do not report as “A B
tobacco wrapped in any substance containing tobacco,
Gold” or “A B Gold Menthol Lights”.
which, because of its appearance, the type of tobacco
used in the filler or its packaging and labeling, is likely to
Column D:
be offered to, or purchased by, consumers as a cigarette
Enter the name and address of the non-participating
described in clause (i) of this definition.
manufacturer.
The term "cigarette" includes "roll-your-own" tobacco
Column E:
(i.e., any tobacco, which, because of its appearance,
Enter the name and address of the person from whom
type, packaging, or labeling, is suitable for use and likely
each cigarette was purchased.
to be offered to, or purchased by, consumers as tobacco
for making cigarettes). For purposes of this definition of
Column F:
"cigarette," 0.09 ounces of "roll-your-own" tobacco
Enter the name and address of the importer of the
constitutes one individual "cigarette."
cigarette (if known).
"Tobacco products distributor" means any person who
meets the definitions found in RCW 82.26.010(3).
Preparation of Schedule
"Cigarette wholesaler" means any person who is licensed
pursuant to Chapter 82.24 RCW.
If more space is required you may copy this form.
Return the completed form 25 days after the close
"Non-participating manufacturer" means any
manufacturer of cigarettes or "roll-your-own" tobacco
of the reporting month.
who is not a signatory to the Master Settlement
Retain a copy for your files.
Agreement. A manufacturer ceases to be a non-
participating manufacturer upon entering into the Master
Please complete this schedule in full and mail to:
Settlement Agreement. A list of Participating
Washington State Department of Revenue
Manufacturers is available at the National Association of
Special Programs Division
Attorneys Generals (NAAG) Web Site,
PO Box 47477
Olympia WA 98504-7477
For tax assistance or to request this document in an alternate format, visit or call 1-800-647-7706.
Teletype (TTY) users may call (360) 705-6718.
REV 82 2109-1 (06/20/05)
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