Form 04-625 - Authorization Of Agent Or Designee To Purchase Cigarette Tax Stamps - Alaska Department Of Revenue
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1
2Voice: 907.269.6620
Department of Revenue
State of Alaska
Fax: 907.269.6644
Tax Division
Authorization of Agent or Designee
550 W. 7th Ave., Suite 500
Anchorage, AK 99501
to Purchase Cigarette Tax Stamps
Authority: AS 43.50.540
The licensee identified in Part I hereby authorizes the entity identified in Part II to purchase cigarette tax stamps on its
behalf. This authorization will remain in effect until the department receives the licensee's written notice of revocation
of the authorization. The licensee understands that designation of another entity to purchase cigarette tax stamps
does not absolve the licensee of its liability to pay the amount due for cigarette tax stamps in the time required by law.
Part I
Licensee Authorizing an Agent or Designee to Purchase Cigarette Tax Stamps
Name
Telephone Number
Fax Number
License Number
Mailing Address
E-Mail Address
City
State
Zip Code + 4
Contact Person
Contact Telephone Number
Check here if you have been authorized to and are paying under a deferred payment plan.
Part II
Agent or Designee Authorized to Purchase Cigarette Tax Stamps on Behalf of Licensee
Name
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
By signing this form, the licensee understands that any cigarette tax liability arising from the purchase of cigarette tax stamps by the Agent or
Designee identified in Part II on behalf of the licensee is the sole responsibility of the licensee.
Signature of Licensee
Printed Name of Licensee
Title
Date
For Department Use Only
Authorization of agent or designee to purchase cigarette tax stamps on behalf of the licensee identified in Part I is acknowledged by
the Tax Division.
Signature
Title
Date
webform 04-625 (New 01/04)
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