Form 04-521 - Unstamped Cigarettes Imported Into Alaska For Personal Consumption

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Department of Revenue
State of Alaska
DEPARTMENT USE ONLY
Tax Division
ENV:
Cigarette Tax Return
550 W. 7th Avenue, Suite 500
Anchorage, AK 99501
Unstamped Cigarettes Imported into Alaska
Telephone 907.269.6620
FSN:
Fax (907) 269-6644
for Personal Consumption
AS 43.50
Federal EIN or SSN
License Number(s)
Period Ending (Year/Month)
AK Business License Number
Name
Telephone Number
Fax Number
Mailing Address
E-Mail Address
City
State
Zip Code
Contact Person
Contact Telephone Number
1. Number of unstamped cigarettes imported or acquired (complete schedule below)…………………… 4
1
2. Tax rate ($.08 per cigarette)…………………………………………………………………………………… 4
2
x $.08
0.00
3. Total cigarette tax due (multiply line 1 by line 2)…………………..………………………………………… 4
3
4. Failure to have a License Penalty (100% of Tax Due) ……………………...……………………………… 4
4
5. Failure to File Penalty (5% of Tax per month)………………………….…………………………………… 4
5
6. Interest…………………………………………………………………….……………………………………… 4
6
7. Violation of Cigarette Shipping Restrictions under AS 43.50.105 ……………………………………..……4
7
8. Total Tax, Penalty & Interest * ……………………………………………………………………………… 4
0.00
8
Check if you are remitting by:
TOPS/ Receipt Number _______________________________
Wire Transfer
To avoid wire transfer fees, use our EFT service, known as TOPS. Go to:
https://
*
YOU MAY MAKE AN ELECTRONIC FUNDS TRANSFER (EFT) USING TOPS OR A WIRE TRANSFER FOR ALL TAX PAYMENTS.
HOWEVER, IF THE AMOUNT DUE IS $100,000 OR MORE, YOU MUST PAY BY EFT OR WIRE TRANSFER IN ACCORDANCE WITH 15 AAC
05.310
Schedule of Unstamped Cigarettes Imported Into Alaska
Date of
Purchase or
Seizure
Supplier's Name and Address
Number of Cigarettes
Total Cigarettes (enter here and on line 1)
0
I wish to be licensed. Send me an application.
I do not wish to be licensed, and do not intend on
importing additional untaxed cigarettes.
declare, under penalty of unsworn falsification, that this return has been examined by me and to the best of my knowledge and belief is a true,
I
correct, and complete return of all untaxed cigarettes I imported into Alaska.
Signature
Date
DEPARTMENT USE ONLY
VALIDATION NUMBER
Form 04-521 Webform (Rev 01/05)

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