Iowa Department of Revenue
Marijuana and Controlled Substance
TAX STAMP ORDER FORM
For Office Use Only
(B)
(C)
(A)
Number
Tax
Tax
Stamp
Number of
of Plants
Rate
B x C
Sequence
Stamps
Marijuana
$750.00
Plant Stamps
plant
Total Marijuana Plant
Stamp Purchases
Weight of
Number of
Tax
Stamp
Number of
package (grams)
packages
Tax Rate
A x B x C
Sequence
Stamps
$5.00 / gram
Marijuana
$5.00 / gram
Stamps
$5.00 / gram
Total Marijuana
Stamp Purchases
Weight of
Number of
Tax
Stamp
Number of
package (grams)
packages
Tax Rate
A x B x C
Sequence
Stamps
$250.00 / gram
Controlled
Subtance
$250.00 / gram
By Weight
$250.00 / gram
Total Controlled
Substance by Weight
Quantity
Number of
Tax
Stamp
Number of
per package
packages
Tax Rate
A x B x C
Sequence
Stamps
$400.00 / 10
Controlled
Subtance
$400.00 / 10
By Dosage
$400.00 / 10
Total Controlled
Substance by Dosage
Date Of
Total Tax Paid (Must be $215 or more)
Sale
Payment will be accepted in the form of cash, certified check or money order. No personal check will be accepted.
Mail cash at your own risk.
You are not required to give your name or any other identifing information; however if you are ordering by mail, you must
provide a valid mailing address. Stamps ordered by mail will be mailed first class at the risk of the purchaser.
Mail Orders to: TAXPAYER SERVICES MANAGER
IOWA DEPARTMENT OF REVENUE
PO BOX 10457
DES MOINES, IA 50306-0457
Name / Address
(required only if stamps are to be mailed)
Name
Address
City, State, Zip
70-510
7/4/04