Form DAS-95 "Licensed Cigarette Stamping Agent (Csa) Reporting Schedule for Cigarette Sales in Pennsylvania of Non-participating Manufacturer (Npm) Brands" - Pennsylvania

What Is Form DAS-95?

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

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Pennsylvania Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DAS-95 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Revenue.

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Download Form DAS-95 "Licensed Cigarette Stamping Agent (Csa) Reporting Schedule for Cigarette Sales in Pennsylvania of Non-participating Manufacturer (Npm) Brands" - Pennsylvania

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dAS-95 (AS) 01-18
Licensed Cigarette Stamping Agent (CSA) Reporting
This schedule should be attached
Schedule for Cigarette Sales in Pennsylvania of
to your Monthly Cigarette Stamping
Non-Participating Manufacturer (NPM) Brands
Agent report due the 20th of
BureAu of BuSineSS TruST fund TAxeS
(Instructions on Reverse side)
the month.
Po Box 280909
HArriSBurg, PA 17128-0909
Reporting Month/Year: ______________
(717) 783-9354
Please provide the following information with respect to cigarettes that were made by a Non-Participating Manufacturer (NPM) and that were stamped and sold
in Pennsylvania.
q
Cigarette Stamping Agent License no:
Amended form for reporting period (month/year)
Business name and Address:
q
federal ein:
none (no sales of nPM cigarettes in PA)
Telephone:
fax:
e-mail:
Website:
o. of Cigarettes (Sticks)
Non-Participating Manufacturer Name and Address
Name and Address of the Business/Person(s)
Brand Name
Stamped and Sold Within PA
(If Known)
From Whom Each Brand Was Purchased
(a)
(b)
(c)
(d)
Total of Column b:
Page
of
under penalties of perjury, the undersigned authorized agent of the company states that the company named above verifies that all information contained herein is
true and correct, and gives consent for use of this information to the office of Attorney general to monitor compliance pursuant to Act 54 of 2000, known as the
Tobacco Settlement Agreement Act.
Signature, authorized agent
Printed or Typed name
Title
date
dAS-95 (AS) 01-18
Licensed Cigarette Stamping Agent (CSA) Reporting
This schedule should be attached
Schedule for Cigarette Sales in Pennsylvania of
to your Monthly Cigarette Stamping
Non-Participating Manufacturer (NPM) Brands
Agent report due the 20th of
BureAu of BuSineSS TruST fund TAxeS
(Instructions on Reverse side)
the month.
Po Box 280909
HArriSBurg, PA 17128-0909
Reporting Month/Year: ______________
(717) 783-9354
Please provide the following information with respect to cigarettes that were made by a Non-Participating Manufacturer (NPM) and that were stamped and sold
in Pennsylvania.
q
Cigarette Stamping Agent License no:
Amended form for reporting period (month/year)
Business name and Address:
q
federal ein:
none (no sales of nPM cigarettes in PA)
Telephone:
fax:
e-mail:
Website:
o. of Cigarettes (Sticks)
Non-Participating Manufacturer Name and Address
Name and Address of the Business/Person(s)
Brand Name
Stamped and Sold Within PA
(If Known)
From Whom Each Brand Was Purchased
(a)
(b)
(c)
(d)
Total of Column b:
Page
of
under penalties of perjury, the undersigned authorized agent of the company states that the company named above verifies that all information contained herein is
true and correct, and gives consent for use of this information to the office of Attorney general to monitor compliance pursuant to Act 54 of 2000, known as the
Tobacco Settlement Agreement Act.
Signature, authorized agent
Printed or Typed name
Title
date
Pennsylvania Department of Revenue
Instructions for DAS-95
Licensed Cigarette Stamping Agent Reporting Schedule and Instructions
for Cigarette Sales in PA of Non-Participating Manufacturer (NPM) Brands
DAS-95 (AS) IN 01-18
In accordance with Act 54 of 2000
"Non-participating manufacturer"
Column d:
known as the Tobacco Settlement
(NPM) means any tobacco product
Enter the name and address of the
manufacturer who is not a Participating
Agreement Act, the Department of
business/person from whom each
Manufacturer (signatory) to the tobacco
Revenue is required to compile infor-
brand was purchased if different from
Master Settlement Agreement dated
mation about NPM cigarettes sold in
the person identified in Column c.
Nov. 23, 1998. A tobacco product
this state bearing the PA cigarette
manufacturer ceases to be a non-par-
excise tax stamp. Complete and submit
PREPARATION
ticipating manufacturer upon entering
this schedule along with your monthly
OF SCHEDULE
into the Master Settlement Agreement.
Cigarette Stamping report due the
A listing of Participating Manufacturers
20th of the month.
is maintained and updated at the
Enter your business name and
National Association of Attorneys Gen-
DEFINITIONS
address as they appear on your
eral (NAAG) website, www.naag.org.
license. Also enter your Federal
"Cigarette" means any product that
EIN and the name, telephone,
INSTRUCTIONS
contains nicotine, is intended to be
and Fax numbers of an individual
burned or heated under ordinary
FOR COMPLETING
able to answer questions about
conditions of use, and consists of or
REVERSE SIDE
your report.
contains any of the following: (1) any
Amended reports must include
roll of tobacco wrapped in paper or in
This report must be completed for
sales of NPM cigarettes for an
any substance not containing tobacco;
every cigarette brand that is stamped
entire period.
or (2) tobacco, in any form, that is
and sold within this state and that
functional in the product, which,
The DAS-95 must report full
is not on the list of Participating
because of its appearance, the type
Manufacturer brands noted on
calendar months
of tobacco used in the filler, or its
NAAG’s website.
Amended reports are required
packaging and labeling, is likely to be
for months with returned sales.
Column a:
offered to, or purchased by, consumers
Enter the full brand name of the
If CSA has no NPM sales, check
as a cigarette; or (3) any roll of tobacco
product sold (do not abbreviate). Do
wrapped in any substance containing
applicable box.
not break down into sub-categories,
tobacco, which, because of its appear-
If more space is required, you
such as regular, menthol, light, etc.
ance, the type of tobacco used in the
may copy this form.
For example, for a cigarette named
filler or its packaging and labeling, is
"Alpha Bravo Gold Menthol Lights",
Attach the completed form to your
likely to be offered to, or purchased
report only "Alpha Bravo Gold". Do
Monthly Cigarette Stamping Agent
by, consumers as a cigarette described
not report as "A B Gold" or "A B Gold
Report due the 20th of each
in clause (1) of this definition.
Menthol Lights".
month. Each report must be
See Act 54 of 2000, known as the
signed by an authorized repre-
Column b:
Tobacco Settlement Agreement Act.
sentative of your business.
Enter the number of individual NPM
"Tobacco product manufacturer"
cigarettes (sticks) sold monthly in
We do not accept negative stick
means any person who meets the
Pennsylvania in packages to which
counts.
definitions found in Act 54 of 2000,
you affixed the PA cigarette excise
Retain a copy for your files.
known as the Tobacco Settlement
tax stamp. This includes NPM sample
Agreement Act.
cigarettes. Do not list cigarettes that
Please complete this schedule in
were purchased with the PA cigarette
full and mail to:
"Licensed cigarette stamping agent"
excise tax stamp already affixed.
PA Department of Revenue
means any person who is licensed
Bureau of Business Trust
Column c:
pursuant to Article XII of the Tax
Fund Taxes
Reform Code, known as the Cigarette
Enter the name and address of the
PO BOX 280909
Tax Act, and Cigarette Tax Regulation,
non-participating manufacturer of
Title 61, Article III of the PA Code.
the brand (if known).
Harrisburg PA 17128-0909
1
www.revenue.pa.gov
DAS-95
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