Form Att-67 - Report Of Non-Tax Paid Tobacco Products Received By Retailer
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ATT-67 (Rev. 1/13)
Report to be filed within
Georgia Department of Revenue
24 hours of receipt
Alcohol and Tobacco Division
(Regulation 560-8-2-.02)
Telephone (404) 417-4900
Email:
ATDIV@dor.ga.gov
Report of Non-Tax Paid Tobacco Products Received by Retailer
Submit online at
https://gtc.dor.ga.gov
Legal Business Name
STI#
State License No.
For Calendar Month & Year
Address (Street)
City
State
ZIP Code
Loose
Smokeless
Large Cigars
From Whom Purchased
Tobacco
Little Cigars
Date
Invoice
GA License
(Wholesale
(Wholesale
(Address, City, State)
(Wholesale Cost
(Quantity)
Received
Date
No.
Cost Price)
Cost Price)
Price)
1
2
3
4
5
6
7
8
9
10
11
12
AFFIDAVIT
I certify, under the penalties for filing false reports, that I have personal knowledge and understanding of statements made
in this return and that the figures presented herein, including accompanying schedules, are true, correct and complete to
the best of my knowledge and belief, and are filed in accordance with the law.
_____________________________________________________________________________________
Signature of Owner, Partner or Officer
Title
Date
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