Form 04-620 - Alaska Cigarette Tax Stamp Order Form - Department Of Revenue

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Department of Revenue: Tax Division

550 W 7th Ave Ste 500

Anchorage, AK 995011

907.269.6620

fax 907.269.6644

batch #



Alaska Cigarette Tax Stamp Order Form

receipt #

Authority: AS 43.50. This form is available online at

order #

federal EIN or SSN

license number

period ending (year/month)

AK business number

name

telephone

fax

mailing address

contact person

contact telephone

city

state

zip code

Payment is due at the time of order, unless you are approved for deferred payment. Payment must be in the form of a certified or cashier's check or U.S. Postal

money order made payable to the "Alaska Department of Revenue"; or by wire transfer or electronic funds transfer (EFT) through TOPS, the State of Alaska's online

EFT service (see below for web site). In special circumstances, the department will accept a company check (see instructions).



You must make a wire transfer or electric funds transfer (EFT) in accordance with 15 AAC 05.310 if the amount due is $100,000 or more.

To avoid wire transfer fees, use the free online EFT service known as TOPS. Go to: https//

date sent

receipt number

Check if you are remitting by:

wire transfer

TOPS

Check here if you are paying under a deferred payment plan. See instructions for information. If payment is authorized under a deferred payment plan,

payment is due by the end of the month following the month the stamps were ordered.

Filling of Stamp Orders: For those paying under a deferred payment plan, stamp orders will be filled within the same business day provided the order is received

before 10 a.m. AST. For all others, stamp orders will be filled once verification of funds has been received (see instructions).

Stamps - Order by multiplying the number of stamps by the stamp price. See page 1 of instructions for definitions of PM and NPM cigarettes.

PM Cigarettes

NPM Cigarettes

PM Cigarettes

20 cigarettes/pack

25 cigarettes/pack

machine stamp rolls

hand-applied stamps

1. Type and quantity of stamps .......................................................................

(15,000/roll)

(lots of 150 stamps)

(sheets of 150 stamps)

2. Numer of rolls, lots, or sheets .....................................................................

3. Total stamps. Multiply line 1 by line 2 .........................................................

4. Value of each stamp ...................................................................................

$1.80

$2.05

$2.25

5. Tax. Multiply line 3 by line 4 ........................................................................

6. Cigarette tax due. Add the total of all columns in line 5 ..............................................................................................................................

7. Cigarette tax paid with order .........................................................................................................................................................................

type or print name

title

date

signature of taxpayer or authorized purchaser

date filled

Stamp Order

Funds

filled by

checked by

funds verified by

date

Webform 04-620 (rev 06/2006)