Form 69-304 - Texas Cigarette Tax Stamp Order

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69-304
(Rev.9-11/6)
Texas Cigarette Tax Stamp Order
* Stamp orders must be submitted prior to 1:00 p.m.
You have certain rights under Chapters 552 and 559,
Government Code, to review, request and correct information
Date
Distributor code
we have on file about you. Contact us at the address
or phone number listed on this form.
Distributor name
DBA name
Location address
City
State
ZIP code
Contact name for stamp orders
Contact phone number
Contact FAX number
NOTE: Orders will be processed if sufficient funds are available.
Payment method (COMPTROLLER USE ONLY)
CASH
DRAFT
TRUST
Send payment via electronic payment method.
STAMPS REQUESTED
TYPE
QUANTITY
UNIT PRICE
INCREMENTS
STAMP VALUE
H-4/20’S
1.41
30,000/ROLL
N-6/20’S
1.41
1500/PAD (CAMEL WIDE)
N-7/20’S
1.41
1500/PAD
N-2/25’S
1.7625
1000/PAD (CENTURY)
H-3/25’S
1.7625
7,200/ROLL (AMERICAN)
H-5/25’S
1.7625
7,200/ROLL (MEYERCORD)
GROSS AMOUNT DUE
<STAMP CREDITS>
NET AMOUNT DUE
<2.5% DISCOUNT>
<PRIOR OVERPAYMENT>
+ PRIOR BALANCE/LIABLITY
TOTAL TAX DUE
REGISTERED
FDX STANDARD
FDX 2 DAY
UPS
PICKUP
FDX OVERNIGHT PRIORITY
HOLD FDX LOCATION*
OTHER
* IMPORTANT NOTE: Must enter the FDX physical location address
FAX order form to: COMPTROLLER OF PUBLIC ACCOUNTS
Tax Applications and Tobacco Tax Section
FAX: (512) 936-0019
If you have any questions regarding this form or the stamps, please contact one
of our tax specialists at (800) 862-2260 or (512) 463-3731.

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