Claim For Refund Of Cigarette Tax - Washington Department Of Revenue
ADVERTISEMENT
1State of Washington
C
T
C
F
R
IGARETTE
AX
LAIM
OR
EFUND
Department of Revenue
Special Programs Division
A
T
I
I
ND
AX
NDICIA
NSPECTION
Cigarette Tax Program
PO Box 47477
Olympia, WA 98504-7477
Firm Name
Date
/
/
Address
Registration Number
City And Zip Code
Distributor Number
Claim For Refund of Cigarette Tax
Indicate Reason For Refund
:
The above named firm returned to the manufacturer packages of cigarettes with Washington state cigarette tax stamps affixed. These
cigarettes were returned because they were unfit for sale.
Name of Manufacturer
The above named firm claims a refund, as indicated in the amount below, due to malfunction of the stated cigarette stamping
equipment. All improperly stamped packages have been verified by an authorized agent of the Department of Revenue.
20’s
25’s
Tax Exempts
No. of stamps returned to
Manufacturer or Revenue
Jams or Burns
Double Stamps
Partial Stamps
Stamps on Flaps
25’s
=
×
$
$ 1.03125
l l
Total Number
20’s
=
×
$ .825
$
of Stamps
l l
Tax Exempts
Less Discount Total
25’s + 20’s =
×
$ .004
(–) $
Number of Stamps
l l
Total Net Refund Due
$
l l
The undersigned, under the penalty of perjury, states that all of the information contained on this form is true, correct and accurate in every
particular.
(
)
Signature of Firm Representative
Telephone Number
CIGARETTE TAX INDICIA INSPECTION (For Department of Revenue Use Only)
Stamping Machine Numbers:
A cigarette inspection was conducted on the above listed stamping equipment at said firm, place and date. The following conditions existed:
Yes
No
Refund Due
Yes
No
Stamp is Properly Applied to Package
Yes
No
Machine Operates Properly
Yes
No
Equipment Operating When Inspected
Yes
No
Stamp is Legible
Yes
No
Notified Stamping Equipment Service Firm in Case of Problem
Approximate Unstamped Inventory Awaiting Stamping
Approximate Unstamped Inventory Set Aside For
Are Unstamped Stocks For Authorized Persons
(Cases)
Authorized Sales (Cases)
Segregated?
Yes
No
Agent’s Remarks
Signature of Department of Revenue Field Representative
Date
/
/
If you have any questions, please contact the Cigarette Tax Program at (360) 753-5564.
To inquire about the availability of this document in an alternate format for the visually impaired or in a language other than English, please call (360) 753-3217.
Teletype (TTY) users may call (800) 451-7985.You may also access tax information on our Internet home page at
DISTRIBUTION:
WHITE - Miscellaneous Tax, Olympia
YELLOW - Wholesaler
PINK - DOR Agent
REV 82 2063 (8-07-98)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial