REV-1043 AS (11-09)
CIGARETTE STAMPING
Federal Employer ID #
AGENT PURCHASE ORDER
BUREAU OF BUSINESS TRUST FUND TAXES
CIGARETTE TAX INDICIA
PO BOX 280909
CSA #
HARRISBURG PA 17128-0909
Date
PRINT OR TYPE ALL INFORMATION AND RETAIN A COPY FOR YOUR RECORDS.
TO:
Department of Revenue
Please provide name and address of company, Cigarette Stamping Agent (CSA) number and indicate denominations and
quantities as requested in the area to be completed by the CSA.
Agency Name
Telephone
Street Address
Fax
City
State
ZIP Code
Web address
STAMPS:
CS1B
CS2A
CS2B
CS4A 25's
CS5A 25's
CS6A Water
Fuson Rolls
Fuson Sheets
Fuson Sheets
(1x10 Carton)
(2x4 Carton)
(10 Pack)
Fed Ex
PAYMENT: Cash
Charge
SHIPPING METHOD: UPS
Fed Ex
Account Number
TO BE COMPLETED BY CSA
FOR DEPARTMENT USE ONLY
QUANTITY
VALUE
STAMP SERIAL NUMBER(S)
TOTAL VALUE
OF STAMPS
OF STAMPS
$
$
SUBTOTAL OF THIS ORDER
$
LESS CREDIT(S)
NET SALES VALUE
LESS COMMISSION .87% (.0087)
NET REMITTANCE
$
No commission allowed on purchases of less than $100 - Gross Value. Checks
DEPARTMENT USE ONLY
made payable to PA Department of Revenue are accepted, subject to final pay-
ment and at risk of payer. Deduct credit memos from gross value before calcu-
CSA ACCOUNT
lating your commission.
BALANCE
DUE
Stamp Distribution Center
AMOUNT OF
THIS ORDER
Accepted By
TOTAL
Signature
BOND
PAYMENT
Date
TOTAL
AMOUNT
OF
TELEPHONE: (717) 783-9374
BOND
FAX: (717) 705-8413
TT#: 1-800-447-3020
VERIFIED
(Service for Taxpayers with Special Hearing
BY
and/or Speaking Needs)