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SS TOBACCO MANUFACTURER/WHOLESALER S REPORT OF SALES Account Number Non-Resident Name and address of purchaser/seller Name of common carrier Purchaser s PA tobacco products license number Did the purchaser pay the tax - yes or no? If no tax is collected you must retain a copy of the completed Tobacco Products Exemptions Certificate (REV-1042) received from the purchaser for four years. Invoice Date 1. PURCHASER S/SELLER S NAME AND ADDRESS 5. INVOICE DATE 6. INVOICE NUMBER 6. 7. 8. 9.

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