Form Ct-114 - Quarterly Report Of Wisconsin Tax-Paid Cigarettes Purchased
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2CT-114: QUARTERLY REPORT
OF WISCONSIN TAX-PAID
Tax Account Number
CIGARETTES PURCHASED
FEIN / SSN
Quarter Ending (MM DD YYYY)
Use BLACK INK Only
Cancel my permit effective
Legal Name
Business Name (DBA)
(MM DD YYYY)
Check if address, name, or entity
Permit/Business Address
change
Check if this is an amended return
State
City
Zip Code
Check if correspondence is included
Permittees who receive only tax-paid cigarettes with Wisconsin cigarette stamps affixed must complete this report on a quarterly basis
and file it electronically with the Wisconsin Department of Revenue. Enter all purchases as single cigarettes not packs or cartons.
A “multiple retailer” permittee must also prepare a separate report for each store location in Wisconsin. The reports must be attached to
a cover sheet listing the following retailer information: Wisconsin sales tax account number, store name (DBA), address, and cigarette
total for the quarter. Enter the grand total on line 16 of your cover sheet.
Invoice
Purchased From
WISCONSIN
STAMPED
Date
Number
Name
Tax Account Number
Line
Single Cigarettes
1
2
3
4
5
6
7
8
9
10
11
12
13
SUBTOTAL (add lines 1 through 13)
14
15
Amount brought forward from line 50 on the reverse side of this form
16
GRAND TOTAL FOR QUARTER (add lines 14 and 15) Complete this line only on final page of report ►
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)
Preparer’s Phone Number
Date
(
)
CT-114 (R. 1-12)
Wisconsin Department of Revenue
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