Form B-A-20 "Cigarette Manufacturer's Affidavit (Unsalable Cigarettes)" - North Carolina

What Is Form B-A-20?

This is a legal form that was released by the North Carolina Department of Revenue - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2010;
  • The latest edition provided by the North Carolina Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form B-A-20 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Revenue.

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Download Form B-A-20 "Cigarette Manufacturer's Affidavit (Unsalable Cigarettes)" - North Carolina

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Cigarette Manufacturer’s Affidavit
B-A-20
Web
(Unsalable Cigarettes)
2-10
North Carolina Department of Revenue
Name of Manufacturer
Street Address of Manufacturer
Date The Manufacturer Received
the Returned Product
City
State
Zip Code
(MM-DD-YY)
From (Name of Wholesaler or Distributor)
Authorization Number
Street Address Where Original Product Was Shipped
City
State
Zip Code
The undersigned, being duly sworn, states:
1. That the unsalable cigarettes described below on which the North Carolina Cigarette Excise Tax has been paid were received
from __________________________________________________________________________
_______________________________________
Name of North Carolina Distributor
License Number
_________________________________________________________
____________________________________________________________
Street and Number
City and State
2. That all the packages of cigarettes listed above have been destroyed, and that none of the cigarettes returned by the distributor will be reshipped or
sold in the State of North Carolina.
Packs received as N.C. tax-paid under
No. of Cigarettes
Tax Value
Reporting Method (effective 1/1/94)
No. of Packs
Per Pack
Each Pack
Gross Tax Value
Brand Name
Brand Name
Brand Name
Brand Name
The undersigned states, under the penalty of perjury, that all the information contained on this form is true and accurate.
Please attach the credit memo and/or any invoices for substantiation.
Name of Manufacturer on whose behalf affidavit is made
Signature and Title of Affidavit
Date
The State of ___________________________ County of ___________________________________________________________________________
Subscribed and sworn before me a Notary Public in and for the County and State on this _____________________________________________ day of
_______________________________________ 2010.
Commission Expires
Notary Public
North Carolina Department of Revenue, Tobacco Products Unit, PO Box 25000, Raleigh, North Carolina 27640-0001
Cigarette Manufacturer’s Affidavit
B-A-20
Web
(Unsalable Cigarettes)
2-10
North Carolina Department of Revenue
Name of Manufacturer
Street Address of Manufacturer
Date The Manufacturer Received
the Returned Product
City
State
Zip Code
(MM-DD-YY)
From (Name of Wholesaler or Distributor)
Authorization Number
Street Address Where Original Product Was Shipped
City
State
Zip Code
The undersigned, being duly sworn, states:
1. That the unsalable cigarettes described below on which the North Carolina Cigarette Excise Tax has been paid were received
from __________________________________________________________________________
_______________________________________
Name of North Carolina Distributor
License Number
_________________________________________________________
____________________________________________________________
Street and Number
City and State
2. That all the packages of cigarettes listed above have been destroyed, and that none of the cigarettes returned by the distributor will be reshipped or
sold in the State of North Carolina.
Packs received as N.C. tax-paid under
No. of Cigarettes
Tax Value
Reporting Method (effective 1/1/94)
No. of Packs
Per Pack
Each Pack
Gross Tax Value
Brand Name
Brand Name
Brand Name
Brand Name
The undersigned states, under the penalty of perjury, that all the information contained on this form is true and accurate.
Please attach the credit memo and/or any invoices for substantiation.
Name of Manufacturer on whose behalf affidavit is made
Signature and Title of Affidavit
Date
The State of ___________________________ County of ___________________________________________________________________________
Subscribed and sworn before me a Notary Public in and for the County and State on this _____________________________________________ day of
_______________________________________ 2010.
Commission Expires
Notary Public
North Carolina Department of Revenue, Tobacco Products Unit, PO Box 25000, Raleigh, North Carolina 27640-0001