Form Ctx-Wd-4 - Annual Affidavit - The City Of New York - Department Of Finance
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1CTX-WD-4 2/84
THE CITY OF NEW YORK – DEPARTMENT OF FINANCE
AUDIT DIVISION, CIGARETTE TAX UNIT
345 Adams Street, Brooklyn, NY 11201
ANNUAL AFFIDAVIT
(To be submitted by wholesalers and vending machine operators who only purchase joint New York State / New York City stamped
st
th
cigarettes. All others must file monthly returns on Form #CTX-WD for the fiscal year beginning July 1
and ending June 30
.)
th
(**NOTE: Applicants are required to file on or before August 15
of the Tax Year in question. Failure to comply will require the wholesaler
or vending machine operator to file monthly returns on Form #CTX-WD in this form’s place.)
License Number
Name of Applicant
Street Address
City, State, ZIP
STATE OF NEW YORK
)
) s.s:
COUNTY OF
)
, being duly sworn, deposes and says that he is
Name of Affiant
of the
Title: Owner, Partner, or Officer
Name of Organization (Applicant)
Located at
,
Address
That during the period indicated above the applicant will purchase only packages of cigarettes with joint New York State/New
York City Cigarette Tax stamps affixed thereto. In the event that packages of cigarettes are purchased without having affixed
thereto joint New York State/New York City Cigarette Tax stamps, the applicant will file a monthly Cigarette Tax Return within
fifteen (15) days after the close of the calendar month in which such purchases were made. Cigarette Tax Returns will be
filed monthly thereafter.
On the basis of the representations contained herein, it is requested that this affidavit be accepted in lieu of monthly returns
for year ended June 30,
,
Name of Applicant
Signature of Affiant
Sworn to before me this
Day of
, 20
(Corporate Seal Must Be Affixed If Applicable)
Signature and Title of officer administering oath
My Commission expires
, 20
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