Nyc Cigarette Tax Payment Form

NEW YORK CITY DEPARTMENT OF FINANCE

ENFORCEMENT DIVISION

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NYC CIGARETTE TAX PAYMENT FORM

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Finance

Mail to: NYC Department of Finance, Enforcement Division, CTX Unit, 30-10 Starr Ave., 2nd Fl., Long Island City, NY 11101

Instructions: To insure proper credit, detach the bottom portion and return it with your check or money order

made out to NYC Department Of Finance. Please put your social security number or federal tax identifica-

tion number in the space provided below and on the check or money order.

Indicate the total Number of Untaxed Cartons purchased:

# Cartons: _______________

Indicate the name of the Internet Company ____________________________________________

Indicate the period cartons were purchased From: _____/_____/_____ Through: _____/_____/_____

Excise Tax Per Carton ................................................................................... $ _________________

Total New York City Tax Due .......................................................................... $ _________________

(Multiply number of cartons by $15.)

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Tracking #: ______________________

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PAY M E N T C O U P O N

Complete the payment coupon and detach and mail your payment to:

NYC Department of Finance, Enforcement Division, CTX Unit, 30-10 Starr Ave., 2nd Fl., Long Island City, NY 11101

Keep a copy of the coupon and the tracking number for your records.

Your tracking number will be requested in all correspondence and should be indicated with your payment(s).

Tracking #:__________________

TAXPAYER NAME: ______________________________

ADDRESS: ______________________________

BOROUGH, STATE, ZIP: ______________________________

SSN/EIN: ___________________

Total# of Cartons purchased:_______

Tax per carton: $ ________________

NYC Cigarette Tax Due: $ _________

(Multiply number

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of cartons by $15.)

Total Remittance: $ ______________

It is your responsibility to mail a monthly payment until the entire liability is paid.

A copy of this payment coupon must accompany your payment(s)

CigPayForm 06.17.11