Returned Cigarette Stamp Affidavit Form

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RETURNED CIGARETTE STAMP AFFIDAVIT
CHICAGO DEPARTMENT OF REVENUE
TAX DIVISION - REFUND UNIT
333 S. STATE STREET, SUITE 300
CHICAGO, ILLINOIS 60604-3977
Business name:_____________________________________________________________________________________
Business address:___________________________________________________________________________________
City, state, zip:_____________________________________________________________________________________
FEIN:
-
IBTN:
-
IRIS Account no.
Tobacco Wholesaler's license number:_________________________
A
B
C
D
20 PACK
25 PACK
SAMPLES
OTHER
1. Enter amount of packages, samples, or other cigarettes 1.
2. Tax rate .…………….…..….……….….………….…… 2.
$0.16
$0.20
$0.008
3. Amount claimed (multiply line 1 by line 2)……...…...… 3.
4. Grand total amount claimed for refund (add columns A, B, C, and D from line 3)….. 4.
(
)
5. Less 2.05% commission (multiply line 4 by .0205)……..…..…..……..……….……..…
5.
6. Net amount claimed (subtract line 5 from line 4)………….……...………..…………… 6.
Sworn statement
I __________________________________ being duly sworn under oathe state that I am _____________________________________
Name of taxpayer
Title
of the business noted above and that the amount claimed for refund represents the value of Chicago cigarette tax stamps
affixed to cigarette packages returned on ______________________ to ___________________________________________________
Date
Name
at ___________________________________________________________________ for destruction as unsaleables.
Address
___________________________________________________
___________________________
Signature
Date
Subscribed and sworn before me,
this _________ day of ____________________, 20_______
_____________________________________________
Notary Seal
Notary Public
NOTE: In order to process your claim you must attach this form to the Chicago Business Tax Refund Application.
Revised 01/04

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