Form 04-622 Transfer Of Cigarette Tax Stamps Page 2

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Telephone 907.269.6620
Department of Revenue
State of Alaska
Fax 907.269.6644
Tax Division
Transfer of Cigarette Tax Stamps
550 W. 7th Ave., Suite 500
Anchorage, AK 99501
This form is available online at
Part I - Information About the Licensee Transferring the Cigarette Tax Stamps
Name
License Number
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
Part II - Information About the Licensee Receiving the Cigarette Tax Stamps
Name
License Number
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
Part III Transfer of Cigarette Tax Stamps - See Instructions
Number of
Serial Number(s)
Number of Stamps
Value of Tax
Total Value of Tax
Cigarettes
on Stamps
Transferred
Stamps
Stamps Transferred
Per Stamp
(Required)
(C) x (D)
(A)
(B)
(C)
(D)
(E)
20 (PM)
1.60
25 (PM)
2.00
20 (NPM)
1.85
Reason for the transfer
Signature of Licensee Transferring the Cigarette Tax Stamps
Signature of Licensee Receiving the Cigarette Tax Stamps
Print Name of Signatory
Print Name of Signatory
Title
Date
Title
Date
For Department Use Only
Transfer of Cigarette Tax Stamps Approved
Transfer of Cigarette Tax Stamps Denied
Signature____________________________________________
Title________________________________________________
Date________________________________________________
Form 04-622 Webform (Rev 12/04)

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