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State of Alaska
620
Cigarette Tax Stamp Order Form
Federal ID #
EIN
or
SSN License number
Period (yyyymm)
AK business license number
Business name
Business telephone
Business fax
Mailing address
Contact email
City
State
ZIP + 4
Contact person
Contact telephone
Payment is due at the time of order, unless you are approved for deferred payment. Payment must be in the form of a certified or
cashier’s check or U.S. Postal Money Order made payable to the “Alaska Department of Revenue”; or by wire transfer or electronic
funds transfer (EFT) through the state of Alaska’s online EFT services, TOPS. In special circumstances, the department will accept a
company check (see instructions).
Electronic Payment Information
Note: If your liability exceeds $00,000, you must use the Tax Online Payment System (TOPS) at or wire transfer.
Check if you are remitting by:
TOPS/EFT receipt #
Wire transfer date
Check here if you are paying under a deferred payment plan. See instructions for information. If payment is authorized under a de-
ferred payment plan, payment is due by the end of the month following the month the stamps were ordered.
Filling of Stamp Orders. For those paying under a deferred payment plan, stamp orders will be filled within the same business day
provided the order is received before 10 a.m. AST. For all others, stamp orders will be filled once verification of funds has been re-
ceived by the Tax Division (see instructions).
Stamps - Order by multiplying the number of stamps by the stamp price
See page 1 of the instructions for
PM cigarettes
NPM cigarettes
PM cigarettes
definitions of PM and NPM cigarettes.
20 cigarettes/pack
20 cigarettes/pack
25 cigarettes/pack
Machine stamp rolls
Hand-applied stamps
Hand-applied stamps
Hand-applied stamps
(5,000 per roll)
(lots of 50 stamps)
(sheets of 50 stamps)
(sheets of 50 Stamps)
. Type and quantity of stamps
2. Number of rolls, lots or sheets
2
3. Total stamps. Multiply line by line 2
3
4. Value of each stamp
4
$2.00
$2.00
$2.25
$2.50
5. Tax. Multiply line 3 by line 4
5
$
$
$
$
6
$
6. Cigarette tax due. Add the total of all columns in line 5
7
$
7. Cigarette tax paid with order
Signature of taxpayer or authorized purchaser
Date
Type or print name
Title
Pay online at
Mail to: Alaska Department of Revenue - Tax Division
or make check payable to State of Alaska
550 W 7th Ave Ste 500 • Anchorage AK 9950-3566
Telephone 907.269.6620
FAX 907.269.6644
Stamp order
Date filled
__________
Funds
Filled by __________
Checked by __________
Funds verified by _____________ Date _______________
620
Batch #
Receipt #
Order #
Retain a copy for your records
Form 0405-520.webform (rev 06/07) • page