Sd Eform 0892 - Cigarette Excise Tax Stamp Credit Application
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SD EForm - 0892
V1
State of South Dakota
Cigarette Excise Tax Stamp Credit Application
Distributor ___________________________________ License No. _____________________ Meter No. ___________
Address ____________________________________________________
County _____________________________
City or Town _________________________________ State _______ ___________________ Zip ________________
The damaged and unusable cigarettes described below have been returned to:
Name of Manufacturer _____________________________________________________________________________
Address_________________________________ City _____________________ State________ Zip______________
Shipped Via _______________________________________________________ Date __________________________
In accordance with South Dakota statutes section 10-5-20.1, application is hereby made for a cigarette excise tax stamp
credit memo for the following tax stamps and/or tax stamp impressions affixed to damaged or unsaleable cigarettes
returned to the manufacturer.
Brand
Stamp
No. of Stamps
Face Value
Size of Package No. of Packages
Denomination
of Stamps
0.00
Face Value of Stamps Returned
$___________________________________
Certificate
I hereby certify that, to the best of my knowledge and belief, the within and foregoing report is true and correct, and that
none of these cigarettes will be sold or otherwise disposed of contrary to the provision of SDCL 1967 Section 10-50-20.1.
Signed this _____________________________ day of ____________________ 20 ______________.
Firm: _____________________________________________________________________________________________
Owner: ___________________________________________________________________________________________
Department of Revenue, Special Taxes Division, 445 E Capitol Ave., Pierre, South Dakota 57501-3100
For Department Use Only
Manufacturers Affidavit Received
No. _____________________________________
Dated _______________
Face Value of Stamps $_______________________________ Credit Value @ 95% of Face Value $ _______________
Date Audited _____________________ By __________________ Credit Memo Issued No. _______________________
Approved __________________________________
Special Taxes Division, Department of Revenue
SPT 308 (8/01)
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