Form 69-304 - Texas Cigarette Tax Stamp Order - 2002
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169-304
(Rev.6-02/4)
TEXAS CIGARETTE TAX
Order processed by examiner: (COMPTROLLER USE ONLY)
STAMP ORDER
* Stamp orders must be
Date
submitted prior to 1:00 p.m.
Distributor code
Taxpayer number
Distributor name
LOCATION ADDRESS: ________________________________________________________________________________________
CITY: _______________________________________ STATE ____________ ZIP CODE ____________________
CONTACT NAME FOR
STAMP ORDERS: ________________________________________________________________________________________
CONTACT PHONE
CONTACT FAX
(
)
(
)
NUMBER: ____________________________________
NUMBER: ______________________________________
AREA CODE
AREA CODE
Payment method (COMPTROLLER USE ONLY)
CASH
DRAFT
TRUST
CHECK # __________________________
STAMPS REQUESTED
TYPE
QUANTITY
UNIT PRICE
INCREMENTS
STAMP VALUE
H-4 / 20’S
.410
30,000 ROLL
N-6 / 20’S
.410
1500 PAD (CAMEL WIDE)
N-7 / 20’S
.410
1500 PAD
1000 PAD (CENTURY)
N-2 / 25’S
.5125
7,200 ROLL (AMERICAN)
H-3 / 25’S
.5125
H-5 / 25’S
.5125
7,200 ROLL (MEYERCORD)
GROSS AMOUNT DUE
STAMP CREDITS
NET AMOUNT DUE
Under Ch. 559, Government Code, you are entitled to review, request,
and correct information we have on file about you, with limited excep-
tions in accordance with Ch. 552, Government Code. To request
3% DISCOUNT CREDIT
information for review or to request error correction, contact us at the
address or toll-free number listed on this form.
TOTAL TAX DUE
Delivery type
REGISTERED
PO EXP MAIL
OVERNIGHT-FED EX
STD-FED EX
PICKUP
AIRBORNE
OTHER
Send payment via ELECTRONIC PAYMENT METHOD
FAX order form to: TEXAS COMPTROLLER OF PUBLIC ACCOUNTS
Tobacco Tax Section
FAX: 512/475-0869
If you have any questions regarding this form or the stamps, please contact the Texas Comptroller’s office at 1-800-862-2260, toll free nationwide, or in
Austin, call 512/463-1693. If you’re calling from a Telecommunications Device for the Deaf (TDD), the toll-free number is1-800-248-4099, or in Austin, call
512/463-4621.
NOTE: ORDERS WILL BE PROCESSED IF SUFFICIENT FUNDS ARE AVAILABLE.
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