Vt Form Ct-642 - Cigarette Tax Stamp Order
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1Vermont Department of Taxes
133 State Street
PO Box 547
Montpelier, VT 05601-0547
*156421100*
Phone: (802) 828-6839
VT Form
CIGARETTE TAX STAMP ORDER
CT-642
* 1 5 6 4 2 1 1 0 0 *
Name of Purchaser
Date
Mailing Address
Federal ID Number
City
State
ZIP Code
-
COST OF EACH
QUANTITY
ITEM
DENOMINATION
TOTAL COST
as of 07/01/2015
Roll of 30,000
20 Cigarette
$90,274.80
$
Sheet of 600
20 Cigarette
$1,805.50
$
Roll of 7,200
25 Cigarette
$27,082.44
$
Sheet of 600
25 Cigarette
$2,256.87
$
TOTAL AMOUNT REMITTED
$
Stamp price is $3.08 per pack of 20, and $3.85 per pack of 25, minus 2.3% prepayment discount.
Method of Payment
(check one)
CHECK
Check #
Date
Amount
Package Tracking Number
Shipping Company
ELECTRONIC FUNDS TRANSFER
EFT Transaction Date
Amount
(802) 828-5787
FAX order to:
OR
Mail to: Vermont Department of Taxes
Miscellaneous Tax Division
133 State Street
PO Box 547
If you have any questions, please call (802) 828-6839.
Montpelier, VT 05601-0547
FOR DEPARTMENT USE ONLY
Order filled by
Date
Received by
Date
Date sent
via
Form CT-642
5454
Rev. 06/15
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