(R2/ 3-09) Indiana Department of Revenue P.O. Box 901 Indianapolis, IN 46206-0901 Report Period Cigarette Brand Family Quarterly Report CT-19 State Form 51482 7-1 to 9-30 10-1 to 12-31 1-1 to 3-31 4-1 to 6-30 Report Due 10-20 1-20 4-20 7-20 Indiana Code 24-3-5.4-17 Distributor Name Distributor License Number Report Period From: mm/yyyy To: mm/yyyy Instructions: Complete the distributor name, license number and the period you are reporting. List the brand family, number of cigarettes, roll-your-own tobacco, and the name and address of distributor from whom cigarettes/tobacco were purchased. “Number of cigarettes” should be cigarette sticks and not packs or cartons. Roll-your-own tobacco should be listed in units. The taxpayer or agent must complete their name, title and telephone number, and date the form is being completed. Report cigarettes when stamped and roll-your-own when excise tax was paid during the immediate preceding 3 months. Note: The term “roll-your-own” tobacco is any tobacco which because of its apprearance, type, packaging, or labeling, is suitable for use and likely to be offered to, or purchased by consumers as tobacco for making cigarettes. Nine-hundredths (0.09) of an ounce of “roll-your-own” tobacco constitutes one (1) individual cigarette or unit. Brand Family Number of Cigarettes (sticks) Roll-Your-Own Tobacco (units) Purchased from Name and Address Attach additional sheets if necessary. Forms may be obtained from Questions related to this form call (317) 615-2710 I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and statements is true, correct, and complete to the best of my knowledge and belief. Signature of Taxpayer or Agent Title Telephone Number Date American LegalNet, Inc. www.FormsWorkFlow.com