Annual Tobacco Sales Reporting Form

SD EForm - 2121 V1 Annual Tobacco Sales Reporting Form South Dakota Department of Revenue 445 E. Capitol Ave, Pierre, SD 57501-3185 1-800-TAX-9188 Sales Tax License Number: Owner Name: Business Name: Address: Phone Number: Email Address: Cigar Bar Any establishment meeting the requirements of SDCL 34-46-18 may permit the smoking of cigars and any premium tobacco product purchased on the premises. Establishments meeting the requirements of this statute are to report annually to the Department of Revenue the revenue generated from the sale of cigars as a percentage of annual gross income. The establishment must generate ten percent or more of its annual gross income from the sale of cigars. A cigar is any individual roll of tobacco that has a wrapper or cover consisting only of tobacco, that measures a number forty ring size or larger, and that is sold without a filter. If your establishment meets the requirements of a cigar bar please complete the section below. YEAR Annual gross income Cigar income Percent of total 0.00 % Retail Tobacco Store Any retail tobacco store meeting the requirements of SDCL 34-46-19 may permit smoking on the premises. Any retail tobacco store meeting the requirements of this statute are to report annually to the Department of Revenue the revenue generated from the sale of tobacco, tobacco products, and accessories for such products as a percentage of annual gross income. The store must generate sixty-five percent of its annual gross income from the sale of tobacco, tobacco products, and accessories for such products. If your establishment meets the requirements of a retail tobacco store please complete the section below. YEAR Annual gross income Tobacco income Percent of total 0.00 % I declare that the information on this form is correct and complete to the best of my knowledge and belief. _____________________________________________________________________________ Name: Title: Date: American LegalNet, Inc. www.FormsWorkFlow.com