Cigarette Tax Claim For Refund Form - Washington Department Of Revenue

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State of Washington
Department of Revenue
Special Programs Division
Cigarette Tax Claim for Refund
PO Box 47477
Olympia, WA 98504-7477
for rates effective on or after May 1, 2010
Firm Name
Date
Address
Registration Number
City, State, Zip Code
Distributor Number
Reason For Refund:
The above firm has returned to the manufacturer packages of cigarettes with Washington State cigarette tax stamps
affixed. These cigarettes were returned because they were unfit for sale.
Name of Manufacturer
Distributors with their own Certificate of Destroyed Goods – see page 2.
An authorized agent of the Department of Revenue has verified improperly stamped packages of cigarettes as
identified below.
20's
25's
No. of Stamps Returned to Manufacturer
or Revenue or Certified Destroyed
Jams or Burns
Double Stamps
Partial Stamps
Stamps on Flaps
Stamps Marked Off
Total No.
25's =
0
X $3.78125
$
0.00
of Stamps
X $3.025
$
20's =
0
0.00
Less Discount
25's + 20's
X $ .006
(-)$
0
0.00
Total No. of Stamps
$
Total Net Refund Due
0.00
I certify under penalty of perjury under the laws of the
State of Washington that the foregoing is true and correct.
Signature of Firm Representative
Telephone Number
Next Page
For Department of Revenue Use Only
Agent's Remarks
Signature of Department of Revenue Field Representative
Date
If you have any questions, please contact the Cigarette Tax Program at (360) 570-3265.
For tax assistance visit dor.wa.gov or call 1-800-647-7706. To inquire about the availability of this document in an alternate format
for the visually impaired, please call (360) 705-6715. Teletype (TTY) users may call 1-800-451-7985.
)
REV 82 2063B (6/28/10

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