Form Ct 4a - Cigarette Tax Stamp Order - Indiana Department Of Revenue
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1Entry No. ___________________
CIGARETTE TAX STAMP ORDER
CT 4A
State Form 46862
Mail to:
Date ________________________
(R/ 6-02)
Indiana Department of Revenue
Registration No. _________________
Post Office Box 901
Indianapolis, Indiana 46206-0901
Quantity
Description
Price
Amount
¢
Rolls of 30M 55.5 Stamps, 20 Cigarettes
$16,650.00/roll
$______________________
Serial Nos.
$ 83.25/sheet
Sheets of 150 55.5¢ Stamps, 20 Cigarettes (WIDES)
$______________________
Serial Nos.
$ 0.555/each
Fuson Stamps, 20 Cigarettes
$______________________
Serial Nos.
$ 0.12/each
$______________________
Cigarette Papers
Serial Nos.
Total
$______________________
Discount-1.2%
$______________________
Net Amount
$______________________
Postage
$______________________
Total Amount
$______________________
Enclosed Please Find Our Remittance
}
Payable to: Indiana Department of Revenue
Firm Name (Printed or Typed)
OR
Street and No.
As a Distributor Bonded for Payment
of this Tax, Charge our Account.
City
State
Zip
By
(Check Applicable Box)
Authorized Agent & Title
Send both copies -- Yellow Copy returned with order
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