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Dbpr Form Ab&t 4000a-004 - Request For Credit Or Refund Of Cigarette Indicia December 2003

DBPR Form AB&T

DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION

4000A-004

DIVISION OF ALCOHOLIC BEVERAGES AND TOBACCO

Rev. 12/03

1940 NORTH MONROE STREET • TALLAHASSEE, FL 32399-1022

REQUEST FOR CREDIT OR REFUND OF CIGARETTE INDICIA

Distributor's Name

Phone No. (

)

Permit No.

Address

City

State

Zip

PART I: CERTIFICATE OF RETURN / DESTRUCTION

RETURNED TO MANUFACTURERS - Must be accompanied by applicable Manufacturers' affidavits of product return

DESTROYED

- Must be witnessed and accompanied by a signed product destruction form from Division of Alcoholic Beverages and

Tobacco personnel

Non Tax Paid

Tax Paid Packages

and Unstamped Packages

20s

25s

20s

25s

American Brands

Brown & Williamson

Liggett & Myers

Lorillard

Philip Morris

RJ Reynolds

Other:

TOTALS

Date

CWD's AUTHORIZED REPRESENTATIVE

AB&T TAX AUDITOR / AGENT

Attesting to Returns to Manufacturer

Attesting to Product Destruction

PART II: TAX COMPUTATION

Tax credits and refunds are calculated at net of the applicable tax rate,

less the CWD 2% discount on the par value of the stamp, up to the first $.24 per package

Packages of 20s

0.3342

per package

Packages of 25s

0.419

per package

Packages of

per package

TOTAL AMOUNT OF CREDIT OR REFUND

CREDIT

REFUND

PART III: REQUEST FOR

*When requesting a refund, a completed form BPR AA-4, Application for Refund from the State of Florida , must be attached.

Pursuant to Chapter 210.05, Florida Statutes, this request is being made for credit or refund, as indicated. The above firm or corporation was the legal owner of the

listed indicia and the statement of the number and value of indicia destroyed or returned is true and correct to the best of my knowledge and belief. This request is

submitted under penalty of perjury.

Typed or Printed Name

Signature

Date

DAB&T USE ONLY

Reviewed by:

Date: