Cigarette Tax Claim For Refund Form - Washington Department Of Revenue Page 2
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2Distributors Certificate of Destroyed Goods. In cases where manufacturers are not
accepting the return of “stale” cigarettes, a Distributor may destroy the cigarettes themselves
and claim a refund for the stamps that were attached. Here are the procedures to follow for
claiming that type of stamp refund.
a) The Department of Revenue (DOR) requires advance notice of the destruction of
the cigarettes and stamps. A DOR authorized agent must be present at the
destruction or DOR must have approved the destruction without an agent being
present. Attach pre-authorization unless destruction has been witnessed by DOR.
b) The method of destruction must be approved by DOR. The cigarettes and stamps
must be made unusable. For example, the cigarettes may not be placed in a
dumpster or landfill without the cigarettes and stamps first being destroyed.
Certificate of Destroyed Goods – Cigarette Tax Stamps.
I am an authorized representative of _________________________________________, a
licensed cigarette wholesaler. We certify that we have destroyed cigarettes unfit for sale, and
the cigarettes had the Washington cigarette tax stamp affixed.
___________________________________________________________________________
Identify date and manner of destruction
I certify under penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct.
___________________________________________________________________________
Signature of Taxpayer or authorized representative /title
Print This Form
If you have any questions, please contact the Cigarette Tax Program at 360-570-3265.
NOTE: This form cannot be saved. You must print it out for your files.
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REV 82 2063B (6/28/10
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