Form 04-520 - Cigarette And Tobacco Products Tax License Application With Instructions Page 2
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State of Alaska
Telephone 907.269.6620
Department of Revenue
Fax 907.269.6644
Tax Division
Cigarette and Tobacco Products Tax
Email
Tax_Cigarette@revenue.state.ak.us
550 W 7th AVE STE 500
License Application
Anchorage, AK 99501
AS 43.50.010-450
License Year
This form is available online at
Is this a renewal?
YES
NO
July 1, 2005 - June 30, 2006
NOTE: Your license will be issued in the individual or corporation name given below. All state tax returns must be filed under the same name
and EIN or SSN. Except for vending machine operators, all persons operating more than one place of business must obtain a separate
license for each place of business.
Taxpayer Name
Federal EIN
or SSN*
Physical Location where this License is Applicable
Business Name
Telephone Number
Mailing Address
Fax Number
License Number
Contact Name
City
State
Zip Code
E-Mail Address
Business Type
Corporation
Partnership
Individual
* Enter a Federal EIN if the business is a corporation or partnership so that the Department of Revenue may administer the tax laws of Alaska AS 43.05.080.
The information is used by the department for identification purposes.
Select License Type Below
See other side for definitions of license types. The license fee must accompany the application.
Please be advised that by applying for a license authorizing the sale of cigarettes, you are agreeing to purchase and affix
cigarette tax stamps, or designate a third party to do so on your behalf, as the means of paying the state excise tax.
License
Cigarettes and Tobacco Products
Fee
Buyer .................................................................................................................................................................. $25.00
Direct-Buying Retailer.......................................................................................................................................... $50.00
Distributor ........................................................................................................................................................... $50.00
Manufacturer ....................................................................................................................................................... $50.00
Vending Machine Operator ................................................................................................................................. $50.00
Wholesaler-Distributor ........................................................................................................................................ $50.00
Tobacco Products Only (Persons who exclusively import and/or acquire tobacco products other than cigarettes)
Distributor ........................................................................................................................................................... $50.00
Make your check payable to: Alaska Department of Revenue or use our free online EFT service known as TOPS.
To use TOPS go to
https://
EFT receipt number ____________________________
Explain, in general, the nature of your business. Indicate the sources of your purchases and to whom you distribute.
I certify that an accurate record will be kept of cigarettes and other tobacco products manufactured, imported, acquired or sold from any source whatever and
that the required returns will be filed on or before the last day of each calendar month and that the tax stamps will be affixed before sale or distribution.
Signature
Title
Date
Form 04-520 Webform (Rev 05/05)
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