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OX 740395 ATLANTA, GEORGIA 30374-0395 MONTHLY REPORT OF CIGARETTES WITH OTHER STATES TAX STAMPS AFFIXED NAME OF DISTRIB U TOR STATE LICENSE NO. FOR CALENDAR MONTH OF: STREET ADDRESS CITY STATE REPORT OF CIGARETTES WITH STATE OF ZIP CODE TAX STAMPS AFFIXED NUMBER BY PACKS OF: 20 s 25 s SUMMARY OF ALL TRANSACTIONS DURING THE MONTH 1. Cigarettes on hand first day of month (Line 6, previous month s report) 2. Cigarettes received into inventor.

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