Indiana Department of Revenue P.O. Box 901 Indianapolis, IN 46206-0901 CT-11 SF 46856 CIGARETTE STAMP PURCHASES INVENTORY OF CIGARETTES AND CIGARETTE STAMPS Revised 7/97 For the period of ______________________, ______ Name of License Holder (as indicated on license) City or Town Mailing Address County Cigarette Distributor’s License# State Zip Code PURCHASES OF CIGARETTE STAMPS (1) Federal ID Number INVENTORY OF UNAFFIXED STAMPS (2) (4) (5) (6) (1) (2) (3) (4) Date Tax State (3) Invoice Number Value of Stamp Number of Stamps Gross Value Tax State Value of Stamps Number of Stamps Gross Value Inventory of Indiana Stamped Cigarettes Inventory of Unstamped and/or Out-of -State Stamped Cigarettes (1) (2) # of Cartons # of Cigarettes Per Carton # OF CIGARETTES (3) Total Cigarettes UNSTAMPED STATE TOTAL American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR FORM CT-11 A. Indicate the period and year for which the return is being filed in the appropriate spaces provided. B. Indicate the Licensed Cigarette Distributor’s name, address, license number, city or town, county, state, zip code and federal identification number in the appropriate spaces provided. PURCHASES OF CIGARETTE STAMPS INVENTORY OF INDIANA STAMPED CIGARETTES All purchases of cigarette stamps be documented regardless which state issued the stamp. (1) Tax State: Indicate the state from which the cigarette stamp was purchased. (2) Date: Indicate the date the cigarette stamps were purchased. (3) Invoice#: Indicate the invoice number which documents the purchase of the cigarette stamps. (4) Value of Stamps: Indicate the value of the cigarette stamps purchased. (5) # of Stamps: Indicate the number of cigarette stamps purchased. (6) Gross Value: Indicate the total value of the cigarette stamps purchased. Only those cigarettes which have an Indiana cigarette tax stamp affixed to the original packages on hand at the close of business the last day of the period are to be included. INVENTORY OF UNAFFIXED STAMPS INVENTORY OF UNSTAMPED AND/OR OUT-OF-STATE STAMPED CIGARETTES (1) # of Cartons: (2) # of Cigarettes per carton: (3) Total Cigarettes: Indicate the number of cartons of cigarettes which have Indiana cigarette stamps affixed to the original packages in inventory at the close of business the last day of the period. Indicate the number of cigarettes per carton for the cartons of cigarettes indicated in the previous column. Indicate the number of cartons multiplied by the number of cigarettes per carton. All cigarette stamps not affixed to original packages on hand at the close of business the last day of the period must be indicated. These stamps are to include Indiana stamps plus any other states stamp in inventory the last day of the period. All cigarettes which do not have an Indiana cigarette stamp affixed to the original package are to be included in this inventory (Salable or Damaged). (1) Tax State: Unstamped: Indicate the state from which the cigarette stamp was purchased. (2) Value of Stamps: Indicate the value of the cigarette stamps in inventory at the close of business the last day of the period. (3) # of Stamps: Indicate the number of cigarette stamps in inventory for the value indicated in the previous column. (4) Gross value: Indicate the total value of the cigarette stamps in inventory. State: # of Cigarettes: Indicate the number of cigarettes in inventory at the close of business the last day of the reporting period which do not have any cigarette stamp affixed to the original package. Indicate the State from which the cigarette stamp was purchased. Indicate the total number of cigarettes in inventory at the close of business the last day of the reporting period. American LegalNet, Inc. www.FormsWorkflow.com