Cigarette Tax Stamp Application And Designation Of Delivery Method - Alaska Department Of Revenue
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1
2State of Alaska
Department of Revenue
Department of Revenue
Voice: 269.6620
Voice: 269.6620
Tax Division
Tax Division
Cigarette Tax Stamp Application and
Fax: 269.6644
Fax: 269.6644
550 W. 7th Ave., Suite 500
550 W. 7th Ave., Suite 500
Designation of Delivery Method
Anchorage, AK 99501
Anchorage, AK 99501
Authority: AS 43.50
This form is available online at
Federal EIN or SSN
License Number
AK Business License Number
Name
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code + 4
Contact Person
Contact Telephone Number
Use this form to apply to the Tax Division to purchase cigarette tax stamps and provide instructions to the Tax Division
designating the method of delivery of cigarette tax stamps purchased by you. AS 43.50.540(e) requires that cigarette
tax stamps be obtained in person from the Division unless you designate in writing an alternative method of delivery.
I will be purchasing cigarette tax stamps from the Alaska Department of Revenue.
Deliver cigarette tax stamps as follows:
Stamps will be picked up from:
Department of Revenue
550 W 7th Ave., Suite 500
Anchorage, AK 99501
by:
Please list all individuals,
authorized to receive Tax
Stamps on your behalf.*
This list should include
yourself if you will be
picking up your tax stamps,
any employee(s), and/or
any Courier service(s)
you may hire.
*For onsite pick-up of Cigarette Tax Stamps, you or your representative will be required to present valid identification for verification purposes.
- - - - - - - - - - - - OR - - - - - - - - - - - -
Ship stamps as indicated:
Name of Receiving Company
If the shipping information is
Mailing Address
Contact Person
different than the taxpayer
information, ship to:
City
State
Zip Code
Ship Via Federal Express ……………………...………………………… Account # :
Ship Via DHL ……………………………………………………………… Account # :
Ship Via UPS ……………………………………………………………… Account # :
Ship Via USPS ……………………………………………………………Account # :
Ship Via Other:
Account # :
Ship Via:
Pick up and billing arrangements
to be coordinated by licensee
Signature of Taxpayer
Type or Print Name
Date
Title
webform 04-621 (New 01/04)
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