Mail To: Indiana Department of Revenue Criminal Investigation Division Indiana Government Center North 100 North Senate Avenue RM N181 Indianapolis, IN 46204-2253 Indiana Department of Revenue Delivery Sales of Cigarette/Other Tobacco Products to Persons in Indiana TOB-101 State Form 51418 (R/03-05) Delivery Sales of cigarettes/other tobacco products into the State of Indiana for the month ending __________/200__. Due Date: 10th day of the calendar month following the month in which Cigarettes/Other Tobacco Products were shipped into the State of Indiana and where the appropriate tobacco taxes were not collected from the purchaser. Merchants Name Federal FEIN or SSN Mailing Address Telephone Number City State Contact Person Zip Code E-Mail Address Title Contact Telephone Number Attach additional sheets as needed. Invoice Date Invoice Number Purchaser’s Name Purchaser’s Address Product Brand Cigarette Number of Sales Price Cigarettes Other Tobacco Products Wholesale Price Sales Price Note: Your own form may be attached if it contains all the necessary information. (For example, a Computer Generated Report) Delivery Sale - A delivery sale is defined in IC 24-3-5-1 as: A transaction for the purchase of tobacco products in which an offer to purchase tobacco products is made: (1) electronically using a computer network (as defined in IC 35-43-2-3); (2) by mail; or (3) by telephone; and acceptance of the offer results in delivery of tobacco products to a named individual at a designated address. American LegalNet, Inc. www.FormsWorkflow.com