Form 70-039 - Iowa Cigarette Refund Affidavit For Cigarettes Returned To Manufacturers

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Iowa Cigarette Refund Affidavit
Iowa Department of Revenue
for Cigarettes Returned to Manufacturers
FOR OFFICE USE ONLY
Permit No.: ___________________________________
Cigarette Tax
Denied
Refunded
FEIN: ________________________________________
Permit Holder Name: ___________________________
Tobacco
Mailing Address: _______________________________
____________________________________________
Approved
Date
DLN
____________________________________________
The above permit holder hereby claims a refund of Iowa cigarette tax in accordance with chapter 453A, Iowa
Code, for unsalable cigarettes and/or little cigars which were returned to the manufacturer after Iowa tax was
affixed.
The following information is submitted in support of this claim and a manufacturer’s verification is attached.
Invoice
No. Packs Tax
Gross
No. Packs Tax
Gross
Manufacturer
Date
No.
20s
Rate
Tax Paid
25s
Rate
Tax Paid
Sub-totals:
Less 2% discount:
Amounts claimed 20s and 25s:
Total refund claimed: .................................. $ ___________
The undersigned states, under penalty of perjury, that all the information contained on this form is
true and accurate in every particular.
Signature and Title: ___________________________________________________ Date: _____________
Subscribed and sworn to before me this _______ day of ______________________ , _______
Notary Public: _______________________________________________________
Mail this form to: Iowa Department of Revenue, PO Box 10456, Des Moines, Iowa 50306
Fed Ex address: Iowa Department of Revenue, 1305 E. Walnut, Des Moines, Iowa 50319
70-039 (06/11/10)

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