| (Business name), (tax reporting number), a dealer in
tobacco products, has returned merchandise unfit for sale. Tobacco tax has been paid on such tobacco products as set
forth above. |
| Returned to: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Date: . . . . . . . . . . . . . . . . |
|
| Method of transport: . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Manufacturer's credit issued on: . . . . . . . . . . . . . . . . . |
| Credit memo number: . . . . . . . . . . . . . . . . . . . . . . . . . . |
Signature of Taxpayer or Authorized Representative:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| Name: . . . . . . . . . . . . . . . . |
|
| Title: . . . . . . . . . . . . . . . . . |
|