Sd Eform - 1965 - Cigarette Tax Amnesty January 2007

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SD EForm - 1965
HELP
V2
Complete and use the button at the end to print for mailing.
Cigarette Tax Amnesty
Administered by the Division of Property and Special Taxes
445 East Capitol Avenue, Pierre, SD 57501-3185
evenue
605-773-7804
Use this form for purchases made after January 1st 2007.
AMNESTY FORM INSTRUCTIONS: Detailed instructions are provided on the back of this form.
Please print or type all required information in the spaces provided below. Form must be signed and dated to be considered valid.
First and Last Name:
SD
Address:
City:
State:
Zip Code:
Phone Number (optional):
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0
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TOTALS
0
$0.00
0
Payment MUST accompany this completed form.
1. EXCISE TAX: ____________ X $1.53 =
0.00
# of packs
Make check payable to: South Dakota State Treasurer.
$0.00
$0.00
Mail completed form and payment to Mickelson Building,
0.00
2. TOTAL TAXABLE AMOUNT: ____________ + ___________ = _____________
Attn: Dept. of Revenue, 1302 E Hwy 14 Suite 1, Pierre,
Total of Invoices
Excise Tax
Total Taxable
SD 57501.
$0.00
3. STATE USE TAX: ____________ X .04 =
0.00
Total Taxable
$0.00
0.00
4. CITY USE TAX: ____________ X __________ =
0.00
Total Taxable
City Tax Rate
5. TOTAL DUE: LINE 1 + LINE 3 + LINE 4 =
0.00
I hereby declare that, to the best of my knowledge and belief, the information provided by me on this form is true, correct and complete. I understand that the
statements I have made on this form are subject to verification.
Signature of Person Completing this Form:
Date:
January 2007
PRINT FOR MAILING
CLEAR FORM

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