Montana Form Ct-203 - Insignias Refund Application

Montana Form Ct-203 - Insignias Refund Application - 2005

MONTANA

CT-203

Rev 1-05

Insignias Refund Application

Business Name

License No.

Date

Principal or Agent Name

Phone

Address

Fax

City

State

Zip

Instruction for form preparation

1. Prepare in duplicate. Submit the original to Montana Department of Revenue, Customer Intake Process, P.O. Box

1712, Helena, MT 59604-1712. Retain a duplicate in company file for field audit purposes.

2. Attach with this refund request all copies of the credit memo, or other documents sent to the wholesaler indicating that

credit or refund of the Montana cigarette tax has been issued.

Section 1 – Refund recap

1. Total value of stamps (total from all schedule M) .................................................... _____________________

2. Discount rate ............................................................................................................

0.0045

3. Total discount (multiply line 1 by line 2) ................................................................... _____________________

4. Net Refund (subtract line 3 from line 1) ................................................................... _____________________

Section 2 – Notary signature

State of ____________________________________________

ss.

County of __________________________________________

___________________________________________________ , being first duly sworn on oath deposes and

says: That he / she is the ______________________________ of the above named applicant, and has

(Title)

personal knowledge of the matter set forth; that the cigarettes are not salable, and the cigarette tax pack units

listed within the attached schedule and which are submitted for refund are all State of Montana cigarette tax

insignia which are affixed to the unsalable cigarettes; that credit or refund for the net cost of the tax insignia has

been given to a Montana cigarette wholesaler and that the cigarettes will not be sold at any time.

___________________________________________________

Signature of Affiant

Subscribed and sworn to before me this ______________ day of ___________ , 20 ______

_________________________________ , Commission expires: ______________________________________

Notary Public Signature

Date

343

Montana Form Ct-203 - Insignias Refund Application - 2005