Cigarette Tax Refund Application Form printable pdf download

NYC DEPARTMENT OF FINANCE

ENFORCEMENT DIVISION

DO NO WRITE IN THIS BOX

OFFICE USE ONLY

C I G A R E T T E TA X

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R E F U N D A P P L I C AT I O N

Finance

Mail to: NYC Department of Finance, Cigarette Tax Unit, 30-10 Starr Avenue, Long Island City, NY 11101

Use this application to claim a refund of the amount paid for stamps affixed to packages of cigarettes with unused or damaged tax

stamps. Please see instructions for additional information and the required documentation that must accompany this application.

S E C T I O N I - A P P L I C A N T I N F O R M A T I O N

1. Name of Applicant/Partnership/Corporation:

2. EIN or SSN:

3. Telephone Number:

4. E-mail Address:

5. Street Address:

City:

State:

Zip Code:

6. Indicate Type of Business

7. NY State License Number:

8. NY City License Number:

(Agent, Wholesaler, Retailer, etc.):

A J

S E C T I O N I I - R E F U N D I N F O R M A T I O N A N D C A L C U L A T I O N S

1. Indicate the reason for the requested refund:

The cigarette tax stamps purchased are no longer required.

The cigarette tax stamps are damaged and unfit for use.

Packages of cigarettes with the tax stamps affixed have become unfit for use and consumption and are unsaleable or have been destroyed.

2. Itemize and total cigarette tax refund information below (see Instructions, Section III, for further details):

Column A

Column B

Column C

Column D

Column E

Column F

Column G

Tax Stamps

Joint Tax Stamp

Number

Total City

Commission

Total City Par Value

Purchased

Par Value

Rate

Amount

Less Commission

Date

(NYC Portion Only)

Tax Stamps

(B X C)

(D X E)

(D - F)

$0.75 (10 Cigarette Package)

$1.50 (20 Cigarette Package)

$1.88 (25 Cigarette Package)

3. Total Amount of Refund Claim:

........................................................................................................................................................................ $

4. Indicate evidence that supports this request for a cigarette tax refund:

NYS Dept. of Taxation and Finance Verification letter

NYS Dept. of Taxation and Finance Inspection Report

NYS Dept. of Taxation and Finance “No Inspection Note”

Other. Please describe: __________________________________________

Evidence indicated must be attached to this application. See instructions for information on required documents.

5. The New York City cigarette tax stamps described above were purchased on the date specified in Column A

YES

for the purpose of affixing them to, or affixed to packages of cigarettes, as required by law..........................................

6. Has a prior application for a refund been made to the Commissioner of Finance of the City of New York

YES

with respect to any of the above-described stamps?. .....................................................................................................

S E C T I O N I I I - C E R T I F I C A T I O N

I, ___________________________________________________________________________________________________________, hereby certify that

Print Name of Owner, Partner or Corporate Officer

this application, together with the accompanying schedules or statements, have been examined by me and are, to the best of my knowledge and belief,

true and complete and made in good faith, pursuant to Title 11, Chapter 13 of the Administrative Code and the regulations issued under authority thereof.

___________________________________________________

_____________________________________________

______________________

Signature

Title

Date

Visit Finance at nyc.gov/finance

CigaretteTax_RefundApplication 06.06.11