Request For Cigarette Tax Credit - Wyoming Department Of Revenue

Request For Cigarette Tax Credit - Wyoming Department Of Revenue - 2011

*0-0-1501-099*

Wyoming Department of Revenue

Excise Tax Division

122 W. 25th Street, Herschler Bldg.

Cheyenne, Wyoming 82002-0110

REQUEST FOR CIGARETTE TAX CREDIT

(Please Print or Type the following information)

______________________________________________________________________________

Wholesale Business Name

Cigarette Wholesalers License #

_____________________________________________________________________________

Business Physical Location Address

____________________________________________________________________________

Contact Person Phone Number(s)

Fax Number(s)

I am requesting a credit of cigarette tax in the amount of $_______________________for the

following

reason(s):_____________________________________________________________________

______________________________________________________________________________

Supporting Documentation Required for Cigarette Tax Credits:

1. Manufacturers affidavit of unsalable or returned cigarettes.

2. Manufacturers affidavit must identify number of cigarette packs with Violet stamps (12

cents) tax paid.

3. Manufacturers affidavit must identify number of cigarette packs with Green stamps (60

cents) tax paid.

______________________________________________________ _____________________

Signature of Claimant

Date

Revised CIGcredit 106, 4/25/11

Request For Cigarette Tax Credit - Wyoming Department Of Revenue - 2011