Form 70-044a - Iowa Cigarette Tax Stamp Order
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1Iowa Department of Revenue
Iowa Cigarette Tax Stamp Order Form
For Office Use Only
Mail to:
Permit Number
Iowa Department of Revenue
Cigarette Stamp Order Processing
PO Box 10472
Purchaser’s Name
Des Moines, IA 50306-0472
Fed Ex mailing address:
Street Address
Iowa Department of Revenue
1305 E Walnut
Hoover Building - 3rd Floor
Des Moines, IA 50319
City, State, Zip Code
Questions:
Walk In
515/281-8807
Units
Stamp Type
Tax Value
Gross Cost
Less 2%
Net Cost
Pack Carton
Stamp
Line
Ordered
Per Unit
Discount
#
Size
Layout
Value
1
20’s
2 x 5
36¢
Roll(s) of 30,000
@$10,800.00
_____________
(old)
2
2 x 5
36¢
Sheet(s) of 150
@$54.00
_____________
3
1 x 10
36¢
Sheet(s) of 150
@$54.00
_____________
(Camel wides)
4
25’s
2 x 4
45¢
Roll(s) of 7,200
@$3,240.00
_____________
(Marlboro 25’s)
5
1 x 10
45¢
Roll(s) of 7,200
@$3,240.00
_____________
6
1 x 10
45¢
Sheet(s) of 150
@$67.50
_____________
Total Remitance Due with Order (Add Net Cost lines 1 through 6). Make check payable to: Treasurer, State of Iowa.
Payment is required with this completed form. No credit available.
Registered Mail
Permit holders may designate the following Receiving Agent (please indicate which one):
Federal Express # _______________________
_______________
______________
______________________________________________
Telephone #
Attention
Signature of Purchaser
Date
For Authorized Agent’s Use only - Stamp Serial Numbers
Stamp Type
Stamp Serial Numbers
Stamp Type
Stamp Serial Numbers
(line #1-6)
(line #1-6)
from
to
from
to
from
to
from
to
from
to
from
to
from
to
from
to
Check Date _________________ Check Number ______________
The undersigned states that he/she is authorized to sell Cigarette Stamps as an agent of the Iowa Department of Revenue and certifies that the
information contained is correct and that the total revenue collected is as stated.
Iowa Department of Revenue or _________________________________________________
Agent’s Organization
_________________________
_________________________________________________
Agent’s Printed Name
Signature of Agent
Date
See reverse side for information on stamps
70-044a (5/17/04)
COPIES:
White - Dept. of Revenue
Yellow - Agent/ Bank or Department
Pink - Taxpayer
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