Form Cig-1 - Distributor'S Cigarette Stamp Order Blank
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1Cig
Maine Revenue Services
00
Distributor’s Cigarette Stamp
Order Blank
*0518000*
Registration Number
Period
-
-
1. Entity Information
Use this area only to report changes in your business
2. OUT OF BUSINESS?
Check here
, return permit to Bureau and
complete information at right. Date closed:
3. OWNERSHIP CHANGE?
If you have changed ownership, indicate the date
when this occured here
and check the type of change below.
Partner added or dropped
Incorporated
Other (explain on reverse)
Sold to
4. NAME CHANGE?
Attach explanation to this return.
ADDRESS CHANGE?: If your address above is incorrect, please
make the appropriate changes to the preprinted address.
Do Not Use Red Ink!
Type of
Stamps
Quantity of Stamps being
Stamp
per Roll
ordered
Amount Due
,
.
,
,
$2.00
5,000
1.
@$2.00 each
Stamp
,
,
,
.
Order
$2.00
30,000
2.
@$2.00 each
,
,
,
.
$2.50
5,000
3.
@$2.50 each
Stamp
Value of Stamps
,
,
,
.
4
.
Number of Stamps Returned
Returned
Returns
,
,
.
5.
Total Due
Total line 1 + line 2 + line 3 - line 4
,
,
.
Discount @ 1.15%
Discount
6
.
Amount
,
,
.
Due
Line 5 minus line 6.
7
.
Credit Due
,
,
.
If line 5 minus line 6 is a credit amount, enter the amount to the right.
8
.
For Office Use Only
Roll #
Roll #
,
,
to
Order #
,
,
to
,
,
to
Dist. by:
Date
,
,
Checked by:
Date
to
,
,
to
Date
Phone #
Signature/Title
Print Name
Cig-1 Revised 07/05
For assistance in completing this form, call (207) 624-9609
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