ATT-30 (REV.01/11) GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER P.O. BOX 740395 ATLANTA, GEORGIA 30374-0395 NAME OF DISTRIBUTOR ADDRESS (Street) OUT-OF-STATE DISTRIBUTOR SALES TO GEORGIA RETAILERS OF TAXED CIGARS, LITTLE CIGARS,AND LOOSE AND SMOKELESS TOBACCO MONTHLY EXCISE TAX RETURN (GEORGIA RETAIL PURCHASES ON NON-TAX PAID PRODUCT) STATE LICENSE NO. CITY RETURN TO BE FILED TH ON OR BEFORE THE10 DAY OF THE FOLLOWING MONTH FOR WHICH THE REPORT IS FILED RETURN FOR THE MONTH AND YEAR OF STATE ZIP CODE LINE # 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. INVOICE DATE INVOICE NUMBER SOLD TO NAME CITY LOOSE TOBACCO (Wholesale Cost Price) SMOKELESS (Wholesale Cost Price) LARGE CIGARS (Wholesale Cost Price) LITTLE CIGARS (Quantity) $ $ $ Total of Sales Schedule (From Line 38 on Reverse Side of Return) Total of Sales (Add Lines 1 ­ 11) Cigars, Little Cigars, and Loose and Smokeless Tobacco Excise Tax Rate by Class Gross Tax Due by Class (Line 12 x Applicable Tax Rate on Line 13) $ 10% $ $ 10% $ $ 23% $ .0025 Gross Tax Due (Total of all Columns in line 14)...................................................................................Remit this Amount with Return AFFIDAVIT I certify, under the penalties for filing false returns, that I have personal knowledge and understanding of the statements made in this return and that the figures presented herein, including accompanying schedules, are true, correct and complete to the best of my knowledge and belief, and are filed in accordance with the law. SIGNATURE OF OWNER, PARTNER OR OFFICER TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE OF CIGARS, LITTLE CIGARS, AND LOOSE AND SMOKELESS TOBACCO SALES TO GEORGIA CUSTOMERS (Continued) Page 2 SMOKELESS (Wholesale Cost Price) LARGE CIGARS (Wholesale Cost Price) LITTLE CIGARS (Quantity) SOLD TO NAME CITY LOOSE TOBACCO (Wholesale Cost Price) LINE # INVOICE DATE INVOICE NUMBER 16. $ $ $ 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. American LegalNet, Inc. www.FormsWorkFlow.com 36. 37. 38. TOTAL (Add Lines 16 ­ 37)... Enter here and on Line 11, Page 1 $ $ $ SCHEDULE OF CIGARS, LITTLE CIGARS, AND LOOSE AND SMOKELESS TOBACCO SALES TO GEORGIA CUSTOMERS (Continued) Page 3 INSTRUCTIONS All out-of-state distributors shipping non-taxed Cigar, Little Cigar, and Loose and Smokeless Tobacco into the State of Georgia to Georgia retailers must complete a Cigar, Little Cigar, and Loose and Smokeless Tobacco Excise Tax Return each month whether or not there are any transactions to report. Any Georgia retailer receiving non-taxed Cigar, Little Cigar, or Loose and Smokeless Tobacco on which the distributor has not paid applicable Georgia excise taxes must complete this form (ATT-30) and remit with the proper payment. The Excise Tax is imposed on Loose and Smokeless Tobacco at the rate of 10 percent of the wholesale price, on little cigars weighing not more than three pounds per thousand at the rate of 2.5 mills each, and on all other cigars at 23 percent of the wholesale price, exclusive of any "consumer promotions." 1. Print or type the Distributor name, address, license number, month and year in the spaces provided on the return. On Lines 1 through 10, enter all sales to Georgia customers into Georgia. If more than 10 sales were made during the reporting period, continue recording sales on Lines 16 through 37 on page 2. 2. Mailing - Sign and date the original return and mail it with remittance due during the month to: Georgia Department of Revenue, Alcohol and Tobacco Division, P. O. Box 49728, Atlanta, Georgia 30359, on or before the 10th day of the following month for which the return is filed. The statutes provide penalties for failure to file this return and pay the tax when due. All records pertaining to tobacco transactions must be retained by the distributor for a period of three years. 3. In accordance with Revenue Regulation 560-8-3-.06(5) the amount of tax due shall be computed on the actual sale or consumption of the tobacco product within the State of Georgia and shall be payable when the tobacco product leaves the control of the distributor for sale or consumption of the tobacco product within the State of Georgia. American LegalNet, Inc. www.FormsWorkFlow.com NOTE: ALL ORIGINAL INVOICES SHALL BE RETAINED ON PREMISE FOR 3 YEARS FROM THE DATE OF REPORT IN ACCORDANCE WITH REVENUE REGULATION 560-8-1-.06. SUCH INFORMATION SHALL BE MADE AVAILABLE TO THE DEPARTMENT ON DEMAND AND AT NO COST INCLUDING, BUT NOT LIMITED TO COPIES, POSTAGE OR ANY RELATED ADMINISTRATIVE COSTS. IF SUCH INFORMATION IS REQUESTED BY THE DEPARTMENT THE SAME MAY BE SUBMITTED ELECTRONICALLY.