Schedule A-1 (Form Rev-1048-A) - Little Cigars Received From Manufacturer During Month

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REV-1048-A AS (10-09)
LITTLE CIGARS RECEIVED FROM
MONTH OF
MANUFACTURER DURING MONTH
SCHEDULE A-1
BUREAU OF BUSINESS TRUST FUND TAXES
YEAR
PO BOX 280909
HARRISBURG, PA 17128-0909
TELEPHONE: 717-783-9374
PAGE NO.
ATTACH TO REV-1030 MONTHLY REPORT
NAME CSA:
ADDRESS (STREET)
(CITY)
(STATE)
(ZIP CODE)
UNSTAMPED LITTLE CIGARS RECEIVED FROM:
(2)
(3)
(4)
(5)
(1)
NUMBER OF
INVOICE
DATE
CREDITS
INVOICE
FOR DEPARTMENT USE
UNSTAMPED
NUMBER
RECEIVED
DATE
LITTLE CIGARS
(PACKS of 20 & 25)
TOTAL (SCHEDULE “A-1”)
NOTE: MAINTAIN DUPLICATE COPY FOR YOUR RECORDS.

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