Form B-A-201 - Other Tobacco Products Manufacturer'S Af Davit (Unsaleable Other Tobacco Products)

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B-A-201
Other Tobacco Products
Manufacturer’s Affidavit
Web
2-10
(Unsaleable Other Tobacco Products)
North Carolina Department of Revenue
Name of Manufacturer
Street Address of Maunufacturer
Date The Manufacturer Received
the Returned Product
City
Zip Code
State
(MM-DD-YY)
From (Name of Wholesaler or Distributor)
Authorization Number
Street Address Where Original Product Was Shipped
City
Zip Code
State
The following Return of Other Tobacco Products is covered by credit memo# ____________________________________________________________
dated __________________________________and includes _________________________________________ packages of Other Tobacco Products.
North Carolina tax paid Other Tobacco Products listed below have been received and destroyed.
Description
Quantity
Cost Price
Brand Name
The undersigned states, under the penalty of perjury, that all the information contained on this form is true and accurate.
Please attach the credit memo and/or any invoices for substantiation.
Dated:
Authorized Agent for Manufacturer
The State of ___________________________ County of ___________________________________________________________________________
Subscribed and sworn before me a Notary Public in and for the County and State on this _____________________________________________ day of
_______________________________________ 2010.
Commission Expires
Notary Public
North Carolina Department of Revenue, Tobacco Products Unit, PO Box 25000, Raleigh, North Carolina 27640-0001

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