Form 04-527 - Cigarette Tax Return

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Department of Revenue
State of Alaska
DEPARTMENT USE ONLY
Tax Division
ENV:
Cigarette Tax Return
550 W. 7th Avenue, Suite 500
Anchorage, AK 99501
Unstamped Cigarettes Seized by Department
Telephone 907.269.6620
FSN:
Fax (907) 269-6644
of Revenue
AS 43.50
Federal EIN or SSN
License Number(s)
Period Ending (Year/Month)
AK Business License Number
Name
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
1. Number of unstamped cigarettes seized (from schedule below)…………...……………...…………….. 4
1
2. Tax rate ($.08 per cigarette)…………………………………………………………………………………… 4
2
x $.08
3. Total cigarette tax due (multiply line 1 by line 2)…………………..………………………………………… 4
3
4. Failure to have a License Penalty (100% of Tax Due) ……………………...……………………………… 4
4
5. Failure to File Penalty (5% of Tax per month)………………………….…………………………………… 4
5
6. Interest…………………………………………………………………….……………………………………… 4
6
7. Violation of Cigarette Shipping Restrictions under AS 43.50.105 ……………………………………..……4
7
8. Total Tax, Penalty & Interest * ……………………………………………………………………………… 4
8
Check if you are remitting by:
TOPS/ Receipt Number _______________________________
Wire Transfer
To avoid wire transfer fees, use our EFT service, known as TOPS. Go to:
https://
*
YOU MAY MAKE AN ELECTRONIC FUNDS TRANSFER (EFT) USING TOPS OR A WIRE TRANSFER FOR ALL TAX PAYMENTS.
HOWEVER, IF THE AMOUNT DUE IS $100,000 OR MORE, YOU MUST PAY BY EFT OR WIRE TRANSFER IN ACCORDANCE WITH 15 AAC
05.310
Schedule of Unstamped Cigarettes Seized by Department of Revenue
Date of Seizure
Supplier's Name and Address
Number of Cigarettes
Total Cigarettes (enter here and on line 1)
I wish to be licensed. Send me an application.
Date
RETURN PREPARED BY THE ALASKA DEPARTMENT OF REVENUE UNDER AUTHORITY OF AS 43.05.050
DEPARTMENT USE ONLY
VALIDATION NUMBER
Form 04-527 Webform (Rev 01/05)

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