Form Rev 82 2063e - Cigarette Tax Claim For Refund - Washington Department Of Revenue
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State of Washington
Department of Revenue
Reset This Form
Special Programs Division
C
T
C
F
R
Cigarette Tax program
IGARETTE
AX
LAIM
OR
EFUND
PO Box 47477
Olympia, WA 98504-7477
Firm Name
Date
Address
Registration Number
City, State, Zip Code
Distributor Number
Reason For Refund:
The above firm has 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 firm claims a refund due to a malfunction of cigarette stamping equipment. An authorized agent of the
Department of Revenue has verified all improperly stamped packages.
20's
25's
No. of Stamps Returned to
Manufacturer or Revenue
Jams or Burns
Double Stamps
Partial Stamps
Stamps on Flaps
Stamps Marked Off
X $ 1.78125
Total No.
$
25's =
0
0.00
of Stamps
X $ 1.425
$
20's =
0
0.00
Less Discount
X $ .004
(-)$
25's + 20's
Total No. of Stamps
0
0.00
$
0.00
Total Net Refund Due
I certify under penalty of perjury under the laws of the
State of Washington that the foregoing is true and correct.
Print This Form
Signature of Firm Representative
Telephone Number
For Department of Revenue Use Only
Agent's Remarks
Signature of Department of Revenue Field Representative
Date
If you have any questions, please contact the Cigarette Tax Program at (360) 664-0700.
For tax assistance, visit or call 1-800-647-7706. To inquire about the availability of this document in an alternate format
for the visually impaired, please call (360) 486-2342. Teletype (TTY) users may (800) 451-7985.
) Distribution: Copy 1 – Special Programs Division, Olympia Copy 2 – Wholesaler Copy 3 – DOR Agent
REV 82 2063e (fill-in) (3-18-02
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