Form Cig-141 - Cigarette Stamp Order Form - Wyoming Department Of Revenue

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T
S
W
HE
TATE
OF
YOMING
D
R
EPARTMENT OF
EVENUE
D
F
, G
Herschler Building ο 2nd Floor West
AVE
REUDENTHAL
OVERNOR
E
J. S
, D
ο
DMUND
CHMIDT
IRECTOR
82002-0110
122 W. 25TH STREET
CHEYENNE, WYOMING
(307) 777-5200 ο
W
C
: dor@state.wy.us
TELEPHONE
E-MAIL
yoming
igarette
WEB SITE
Stamp Order Form
From:___________________________________ License No:___________________
(Name License was issued to)
Contact Person:__________________________ Phone No:_____________________
Fax No:__________________________________
Ship Stamps to:_____________________________________________________________
City:_________________________State______________________Zip________________
Heat Fusion (30,000 to a roll)
Quantity of Stamps….. . __________________
Value at $.60……………$_________________
Less your 6% discount $_________________
Less Credit Memo
$_________________
Amount of Remittance $__________________
Shipping Instructions for stamps shipped to your business:
Carrier and type of service (i.e. next day air, priority): _______________________________
Account number: ____________________________
Do you want shipment insured:
Yes
No
If yes, how much do you want shipment insured for: $______________________
If you are not bonded, CERTIFIED FUNDS or WIRE TRANSFERS are required
.
Submit all orders and remittances to the:
Wyoming Department of Revenue
Cigarette Tax Section
th
122 West 25
Street
Cheyenne, Wyoming 82002-0110
________________________________________________
Authorized Signature
Date
Important Tax Information
Cigarette stamps shall be sold by and purchased from The Wyoming Department of Revenue. The
Department shall only sell stamps to a licensed Wholesale dealer.
Stamps shall be sold to the
wholesaler at a discount of 6% in rolls of 30,000.
Any package of cigarettes found in this state without Wyoming stamps, imprints or impressions
affixed is considered contraband goods and may be seized without a warrant by the Department.
Please note: Stamp orders shall not be filled for wholesalers who are out of compliance with any of
th
our rules. Including but not limited to failure to file the monthly report by the 20
day of each month
following the month of the cigarette sales report period.
Cig-141 Revised 11/01/07
Fax Number: DOR Main: (307) 777-7722 ρ Excise Tax Division: (307) 777-3632 ρ Mineral Tax Division (307) 777-7849 ρ Liquor Division: (307) 777-6255

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