Form Tt-114 - Quarterly Report Of Wisconsin Tax-Paid Tobacco Products Purchased Page 2
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2TT-114: Quarterly Report of Wisconsin Tax-Paid Tobacco Products Purchased
Read instructions before completing form.
Tax Account Number
FEIN / SSN
Quarter Ending
(MM DD YYYY)
Cancel my permit effective
Legal Name
(MM DD YYYY)
Check if change to address, name,
Business Name (DBA)
entity, or email
Permit/Business Address
Check if this is an amended return
City
State
Zip Code
Check if correspondence is included
Purchased From
Invoice
Line
Invoice Price
No.
Date
Number
Name
Tax Account Number
.00
1
.00
2
3
.00
4
.00
.00
5
6
.00
7
.00
8
.00
9
.00
10
.00
.00
11
.00
12
13
.00
14
.00
.00
15
16
.00
17
.00
18
.00
19
.00
20
.00
Subtotal (add lines 1 through 20)
.00
21
.00
Subtotal brought forward from additional sheets
22
23
TOTAL PRICE OF ALL TAX-PAID TOBACCO PRODUCTS PURCHASED (add lines 21 and 22) ►
.00
DECLARATION: I declare under penalties of law that I have examined this report and all attachments and, to the best of my
knowledge and belief, it is true, correct, and complete.
Signature of Permittee (or authorized agent)
Preparer’s Name (please print or type)
Email Address
Preparer’s Phone Number
Date
(
)
TT-114 (R. 12-13)
Wisconsin Department of Revenue
- 2 -
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