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MONTANA C-MFG-1 Rev 1-05 Manufacturer Cigarette Tax Business Name License No. Date Principal or Agent Name Phone Address Fax City State Zip Shipment of complimentary and/or sample cigarettes for month of ______________________ , 20 ____ Instruction for form preparation Prepare in duplicate. Submit original to Montana Department of Revenue, Customer Intake Process, P.O. Box 1712, Helena, MT 59604-1712, with payment. Retain duplicate in company file for field audit purposes. Tax Value / Pack Number of Packs Total Tax 1. Total of packs containing 20..................... $1.70 $ 2. Total of packs containing 25..................... $2.125 $ 3. Total tax due (add line 1 and line 2).................................................................. $ I hereby swear and affirm under penalty of false swearing that the information herein and attachments are true and correct to the best of my knowledge. Print Name of Principal or Agent Date Signature of Principal or Agent 342

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  • 1. MONTANA C-MFG-1 Rev 1-05 Manufacturer Cigarette Tax Business Name License No. Date Principal or Agent Name Phone Address Fax City State Zip Shipment of complimentary and/or sample cigarettes for month of ______________________ , 20 ____ Instruction for form preparation Prepare in duplicate. Submit original to Montana Department of Revenue, Customer Intake Process, P.O. Box 1712, Helena, MT 59604-1712, with payment. Retain duplicate in company file for field audit purposes. Tax Value / Pack Number of Packs Total Tax 1. Total of packs containing 20..................... $1.70 $ 2. Total of packs containing 25..................... $2.125 $ 3. Total tax due (add line 1 and line 2).................................................................. $ I hereby swear and affirm under penalty of false swearing that the information herein and attachments are true and correct to the best of my knowledge. Print Name of Principal or Agent Date Signature of Principal or Agent 342