Form Ct-001 - Native American Tribe'S Claim For Wisconsin Cigarette Tax Refund
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NATIVE AMERICAN TRIBE’S CLAIM FOR
Send Your Claim and Invoices To:
Wisconsin Department of Revenue
WISCONSIN CIGARETTE TAX REFUND
Mail Stop 5-107
PO Box 8900
Madison WI 53708-8900
Read instructions on back before preparing your claim.
(608) 266-8970
1. Name of Claimant (Tribe)
2. Federal Employer ID No.
3. No. of Retail Stores Authorized
4. Address
5. City
6. State
7. Zip Code
8. Dates of Cigarette Purchases Covered By This Refund Claim
Date of first purchase è
Date of last purchase è
REFUND COMPUTATION SCHEDULE
Tribal Computation
Department Use Only
9. Number of tax paid single cigarettes purchased
(per attached “paid” purchase invoices) . . . . . . . . . . . . . . . . . . . . . . . . .
9
10. Number of tax-paid single cigarettes returned or shorted
(per attached credit invoices) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11. Net tax-paid single cigarettes received (line 9 less line 10) . . . . . . . è
11
x .126
x .126
12. Cigarette tax rate ( .126 per single cigarette) . . . . . . . . . . . . . . . . . . . . . 12
13. Cigarette tax paid
(multiply line 11 by line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
$
$
x .70
x .70
14. Tribal refund percentage (70%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15. Total refund claimed
(multiply line 13 by line 14). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . è
15
$
$
Department Use Only (refund authorization area) è
16. Locations of Authorized Retailers (notify department by letter of any retailer name or address changes)
Net Tax-Paid Single Cigarettes Received
Authorized Retail Locations
(purchases less credits)
Doing Business As (DBA)
Business Address
Tribal Computation
Department Use Only
Net tax-paid single cigarettes received (must agree with line 11). . . . . . . . . è
DECLARATION: I declare that I am personally familiar with the information provided on this refund claim and accompanying docu-
mentation and, to the best of my knowledge and belief, it is true, correct, and complete. The cigarettes were sold on our reservation or
trust land to persons other than cigarette retailers or jobbers.
Signature of Preparer
Preparer’s Phone Number
Date
(
)
CT-001 (R. 8-09)
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