Commonwealth of the Northern Mariana Islands Licensed Wholesaler Monthly Reporng Form:
Excise Tax on Parcipang Manufacturer Cigare
and Roll-Your-Own Tobacco
(Schedule A)
Reporng Month/Year: ______________________________
Please provide the following informaon with respect to cigaree scks and “roll-your-own” tobacco made byipng manufacturers for which an excise
tax is dueer request for refund to the CNMI Department of Finance this month. Aach addional sheets as necessary. For a list of ppng
manufacturers and brands visit: www.naag.org/issues.tobacco.
Your Business Name and Address: __________________________________________________________________________________________
Contact Person: _____________________________________________________ Telephone: _________________________________________
I, ____________________________________, do hereby cy under penalty of perjury, that the above-stated informaon is true and correct.
(print name & e)
Signature: ____________________________________________ Date: ________________________
Manufacturer’s Name
(and address if known)
Person(s) from Whom
Purchased
Invoice
(d
)
individual
cigaree
scks
received
roll-your-own
ounces received
or not you
applied for a
refund of excise
tax. If so, state
basis for
refund. Aach
supporng
cigaree scks for
which you are
responsible for
paying the income
tax
Date Number
(e) (f)
Return the completed form 30 days aer the
close of the reporng month. Please complete
this schedule in full and mail to:
Director, Division of Revenue and Taxa
Department of Finance
P.O. Box 5234 CHRB
Saipan, MP 96950
or fax to: (670) 664.1015
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