Form Ct-30 - Cigarette Tax Refund Claim Form - Department Of Revenue Services

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Form CT-30
Department of Revenue Services
Excise Taxes Unit
25 Sigourney Street
Cigarette Tax Refund Claim
Hartford CT 06106-5032
Stamps Affixed to Packages
DRS use only
(Rev. 07/07)
Date Received ______/______ /______
Distributor’s Name (Type or print)
CT Tax Registration Number
Distributor’s Address
FEIN
(A)
(B)
(C)
(D)
(E)
Number of Packs
Brand Name
Stamp Denomination
Stamp Color
Gross Value Stamps (Multiply A by C)
1.
$
2.
$
3.
$
4.
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
5.
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
6. Add Lines 1 through 5.
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
7. Subtract discount 1% (.01)
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
8. Net refund due: Line 6 minus Line 7.
$
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
Reason for Return
Sign This Before A Notary Public
I, being a person over eighteen years of age and being duly sworn, depose and say:
1. If I am not the distributor named above, I have been authorized by that distributor to execute this cigarette tax refund claim on behalf of that distributor; and
2. I have examined this cigarette tax refund claim, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature
Print Name
Title
State of ______________________________________________ County of _________________________________________________________________
On ____________________ , 20 ______ , before me, the undersigned officer, personally appeared _______________________________________________ ,
known to me (or satisfactorily proven) to be the person whose name is subscribed to this instrument and acknowledged that __________________________
executed the same for the purpose described.
In witness whereof I hereunto set my hand. ____________________________________________________________
Signature
My commission expires on __________________________ , 20 ____ .
(Notary Public: affix seal here)
Name of Manufacturer _______________________________________________________________________________________________________________
The cigarettes listed below, to which Connecticut cigarette tax stamps or decals were affixed, were received from
___________________________________________________________________________________________ on ________________________ , 20 ______ .
(A)
(B)
(C)
(D)
(E)
Number of Packs
Brand Name
Stamp Denomination
Stamp Color
Gross Value Stamps: Multiply A by C.
1.
$
2.
$
3.
$
4.
$
5.
$
Sign This Before a Notary Public
I, being a person over eighteen years of age and being duly sworn, depose and say:
1. If I am not the manufacturer named above, I have been authorized by that manufacturer to execute this affidavit on behalf of that manufacturer;
2. The manufacturer named above will not reship these cigarettes into Connecticut; and
3. I have examined this cigarette tax refund claim, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature
Print Name
Title
State of ______________________________________________ County of _________________________________________________________________
On ____________________ , 20 ______ , before me, the undersigned officer, personally appeared _______________________________________________ ,
known to me (or satisfactorily proven) to be the person whose name is subscribed to this instrument and acknowledged that __________________________
executed the same for the purpose described.
In witness whereof I hereunto set my hand. ____________________________________________________________
Signature
My commission expires on __________________________ , 20 ____ .
(Notary Public: affix seal here)

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