Indiana Cigarette Tax Return {CT-115}

CT-115 (10/07) Indiana Cigarette Tax Return Important: Tax is due at time of purchase. Name Social Security Number Please attach a copy of your invoice Total retail price of the cigarettes Total Number of Packs Purchased Multiply number of packs (Line 2) by 0.995 Do not use this space 1 2 3 4 5 6 Date of Tax Payment Date Purchased If Late Include Interest* Make sure the address below shows through window. Indiana Department of Revenue ATTN: Special Tax Divison - CIGTAX P.O. Box 901 Indianapolis, IN 46260-0901 If late, penalty due is 10%, or $5.00, whichever is greater. Total Amount Due (Add Lines 3, 4 and 5) *Contact the Department at 317-615-2564 or go to our Web site www.in.gov/dor, for the current year interest rate. :462060901044: Make your check payable to: Indiana Department of Revenue - CIGTAX Do not send cash as your payment American LegalNet, Inc. www.FormsWorkflow.com