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Department of Revenue
Telephone 907.269.6620
State of Alaska
Tax Division
Fax 907.269.6644
Application to Purchase Cigarette
550 W. 7th Ave., Suite 500
Anchorage, AK 99501
Tax Stamps on Deferred Payment Basis
This form is available online at
Federal EIN or SSN
License Number
License Period
AK Business License Number
Name
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
As provided in Alaska Statute 43.50.550(b), the undersigned, duly licensed by the
State of Alaska under AS 43.50.010 or AS 43.50.035, hereby applies to purchase
cigarette tax stamps on a deferred payment basis in an amount not to exceed
$________________ in any one calendar month.
This application is accompanied by a surety bond executed by a corporation
incorporated under the laws of the State of _________________ and authorized to
engage in business as a surety company in Alaska.
Attach completed form 04-041D (Rev 10/03), Cigarette Tax Surety Bond.
Name of Surety Company
Bond Number
Address (City, State, ZIP Code)
Amount of Bond*
*Note: Amount of bond must be equal to 200 percent of the maximum dollar amount of allowed monthly cigarette stamp purchases.
Signature of Taxpayer or Representive
Date
Title
PRINTED Name and Title of Taxpayer or Representative
For Department Use Only
Application to purchase cigarette tax stamps on a deferred payment basis approved in the amount of $______________.
Application to purchase cigarette tax stamps on a deferred payment basis denied.
Signature__________________________________
If approved, the above-named licensee may
purchase cigarette tax stamps on a deferred
Title______________________________________
payment basis until ______________________
Date
Date______________________________________
Form 04-623 Webform (Rev 12/04)
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