Form 70-057 - Refund Claim Affidavit For Permit Fees, Losses And Tobacco Taxes printable pdf download

Form 70-057 - Refund Claim Affidavit For Permit Fees, Losses And Tobacco Taxes

Iowa Department of Revenue

Refund Claim Affidavit for Permit Fees,

Losses and Tobacco Taxes

Permit or License No.: __________________________

FOR OFFICE USE ONLY

FEIN: ________________________________________

Cigarette Tax

Denied

Refunded

Licensee or Permitee Name: _____________________

Mailing Address: _______________________________

Tobacco Tax

____________________________________________

Approved

Date

DLN

hereby claims a refund of Iowa Cigarette/Tobacco Tax in

accordance with chapter 453A, Iowa Code,

for: (check one)

Refund of Iowa Cigarette Permit fee in the amount of $ ______________

Permit Number _____________ was surrendered to the Department of Revenue

on _______________________ .

Reason for surrender: __________________________________________

Cigarette stamps which were not used because they were:

____ a. Lost due to destruction (Proof of loss must be attached and claim submitted within 30 days.)

____ b. Recalled by the Department or returned to the Department.

Date of loss or recall _____________________

Circumstances of loss: __________________________________________________

Items Lost or Returned

Revenue

Number

Tax

Gross

Less

Net Claim

Indicator

Unused

Rate

Tax

2% disc.

20s stamps

25s stamps

Tobacco products returned to manufacturer, destroyed, or tobacco tax overpayment.

Date of return, destruction or overpayment: ________________ .

(Proof of return or destruction must be attached.)

Reason for claim: ____________________________________________________________

Tobacco tax was paid on these products at the rate of _______ %

Gross claim: __________ less 3.5% discount of __________ = Net Claim of $ ____________ .

The undersigned states under penalty of perjury, that all the information contained on this form is true and

accurate in every particular.

____________________________ ___________

Signature and Title

Date

Subscribed and sworn to before me on this day of ______________ , 20 _ .

Mail this form to: Iowa Department of Revenue, PO Box 10456, Des Moines, Iowa 50306

Fed Ex address: Iowa Department of Revenue, 1305 E Walnut, Des Moines, Iowa 50319

70-057 (06/11/10)

Form 70-057 - Refund Claim Affidavit For Permit Fees, Losses And Tobacco Taxes

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