Form Ct-50 - Certificate Of Cigarette Tax Re-Stamping Credit printable pdf download

Form Ct-50 - Certificate Of Cigarette Tax Re-Stamping Credit

Department of Revenue Services

CT-50

State of Connecticut

Excise Taxes Unit

25 Sigourney Street

Certificate of Cigarette Tax Re-Stamping Credit

Hartford CT 06106-5032

(Rev. 03/05)

Total Face Value

Distributor’s Name (Type or print)

Distributor’s License No.

CT Tax Registration Number

Number and Street

City, Town or Post Office State

Zip Code

FEIN

SSN

I certify:

1a. That ____________ Connecticut cigarette tax stamps or decals of _____________ denomination with a total face

value of $ _____________ have been superimposed over unacceptable stamps in my presence and under my direct

supervision; or

b. That ____________ Connecticut cigarette tax stamps or decals of _____________ denomination with a total face

value of $ _____________ have been applied under my direct supervision to packages of cigarettes contained in

cartons, to the flaps of which heat-applied Connecticut cigarette tax stamps or decals were affixed; and

2. That I have obliterated with a heavy, indelible pencil all stamps represented in the pertinent paragraph above to

prevent their being further claimed for credit.

Total Face Value

1. $ __________________

Less Discount Allowance

2. $ __________________

Net Credit Due

3. $ __________________

The total face value listed above has been entered by me in the distributor’s purchase order record on Purchase Order

dated ___________________________ . The distributor must enter this amount on Line 6 of its monthly cigarette reports.

Final approval by:

Verified by:

Signature of Excise Field Unit Supervisor

Signature of Revenue Examiner

Date

Form Ct-50 - Certificate Of Cigarette Tax Re-Stamping Credit