Form Tt-12 - Virginia Application For Tobacco Tax Credit Certificate - Virginia Department Of Taxation
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3Form TT-12 Virginia Application For Tobacco Tax Credit Certificate
Virginia Department of Taxation
P.O. Box 1301
Richmond, VA 23218-1301
•
Please print or type all information below.
•
If applying for a Bad Debt Credit, also complete and attach Schedule A.
Stamping Agent Name
Permit Number
(Do Not Use This Space)
Number and Street
City
State
ZIP Code
Contact Person
Phone Number
(
)
The above named stamping agent hereby makes application to the Department of Taxation for a tobacco tax credit certificate
for the reason or reasons and in the amount stated below:
Number Of
Tax Value
Reason
Gross Tax Value
Stamps
Each Stamp
1. Stamps Applied on Carton Flaps
2. Unusable Stamps on Defective Rolls
3. Usable Stamps on Unopened Rolls
4. Stamps On Unsalable Tobacco Products Returned to
Manufacturer: Attach Cigarette Manufacturer Affidavit
.
NOTE: You may consolidate multiple affidavits on this application
5. Other (Specify)
6. Bad Debt Credit (Attach a Schedule A for each bad debt credit application.)
7. Total (Add Lines 1 through 6.)
$
8. Less 2% Discount:
$
9. Net Amount of This Application For Credit Certificate (Line 7 minus Line 8.)
$
I certify that this application is true and accurate.
Name of Stamping Agent:
Date:
By (Authorized Signature):
Title:
VA Form TT-12 W
Rev. 8/06
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