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Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines Page 5

NYC DEPARTMENT OF FINANCE

ENFORCEMENT DIVISION

W H O L E S A L E C I G A R E T T E L I C E N S E

A N N U A L A F F I D AV I T

Finance

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

Instructions: This form to be submitted by sub-jobbers and vending machine operators who only purchase joint New York State /

New York City stamped cigarettes. Sub-jobbers and vending machine operators must file quarterly returns on Form CTX-R within

15 days after the end of each quarter (December - February, March - May, June - August, September - November). All others must

file monthly returns on Form CTX-R within 15 days after the end of the month.

License Number:_____________________________________________________

Applicant Name: ___________________________________________________________________________________________

}

Address:__________________________________________________________________________________________________

Number and Street

City:_______________________________________________________________ State: ________ Zip Code: ______________

STATE OF NEW YORK

S.S:

COUNTY OF

______________________________________________________________________________ , being duly sworn, deposes and says that he/she is

Name of Affiant

__________________________________________________________ of the ______________________________________________________

Title: Owner, Partner, or Officer

Name of Organization (Applicant)

Located at ______________________________________________________________________________________________________________

Address

That during the period indicated above the applicant will purchase only packages of cigarettes with joint New York State/New York City

Cigarette Tax stamps affixed thereto. In the event that packages of cigarettes are purchased without having affixed thereto joint New

York State/New York City Cigarette Tax stamps, the applicant will file a monthly Cigarette Tax Return within fifteen (15) days after the

close of the calendar month in which such purchases were made. Cigarette Tax Returns will be filed monthly thereafter.

______________________________________

Name of Applicant

______________________________________

Signature of Affiant

Sworn to before me this

______________ Day of __________________,20 ________

(Corporate Seal Must Be Affixed If Applicable)

__________________________________________________________

Signature and Title of officer administering oath

My Commission Expires __________________________. 20 ________________

Visit Finance at nyc.gov/finance

CTX-WD 07.15.11

Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines Page 5