Form 8a - Cigarette Tax Order Form

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DR 5225 (02/04/08)
8A
Account number
PERIOD
Send to:
month
year
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0003
(303) 866-2570
Liability
Source
(Check one per order)
0800
CIGARETTE TAX ORDER FORM
121
122
123
124
126
The distributor must provide the carrier of choice and the
REQUESTED:
account number prior to the stamps being shipped. Please notify
PADS / ROLLS
(303) 866-2570 if there are any changes to your account.
DO NOT WRITE BELOW THIS LINE
PAD / ROLL NUMBER
thru
PAD / ROLL NUMBER
CALLED IN BY
Wholesaler's authorized signature
Date
PAYMENT DUE DATE
Wholesaler's name and address
Do not make payment for the stamps with this
document. Use the DR 0221 Cigarette Tax
Return to show stamp orders for the month
and pay by Electronic Funds Transfer (EFT).
(100)
00
Gross amount
•
(105)
Discount
Agent's Signature
Shipped / Picked up
(355)
Net Amount
•

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