Fillable Form O-252 - Order Form For Connecticut Cigarette Tax Stamps printable pdf download

Form O-252 - Order Form For Connecticut Cigarette Tax Stamps

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Department of Revenue Services

Form O-252

Registration Walk-In Unit

PO Box 2937

Order Form

Hartford CT 06104-2937

for

(Rev. 06/11)

Connecticut Cigarette Tax Stamps

Complete this form in black or blue ink only.

Distributor’s name (type or print)

Connecticut Tax Registration Number



FEIN

Number and street

Department of Revenue Services (DRS) use only

City or town

State

ZIP code

Date of Purchase

Authorizing signature

Print name and phone number



______/______/______





DRS Use Only

Indicate method of payment:

Charge

Payment with order

Unit Serial Numbers

Denomination

Unit

Quantity

Unit Cost

Amount

(Cigarettes per pack)

From

20 cigarettes



$3.40

(30,000 per roll)

20 cigarettes



$3.40

(150 per sheet)

25 cigarettes



$4.25

(3,600 per roll)

25 cigarettes



$4.25

(100 per sheet)



Total



Less 1% discount

In case of a credit (returned stamps, etc.),

check the appropriate box below on how to

Net amount of tax



apply an overpayment to the account.





Credit



Amount paid for this order

10.





Refund



Balance due this invoice

11.

Make check payable to Commissioner of Revenue Services.

Note: Charge customer payments must be

Signature of person ﬁ lling order (DRS employee)

Date

made within 30 days of the purchase date.

Otherwise, interest will be added at the rate

of 1% per month or fraction of a month on

Signature of person receiving the stamps

Date

any portion that is unpaid 30 days after the

purchase date.

This section must be completed and signed if stamps are to be shipped.



Indicate method of shipment:

FedEx Priority

FedEx Standard

Account number:_______________________________

Account number: ________________________________

The risk that the ordered stamps may not be received by the distributor is borne solely and exclusively by the distributor. In the event that the ordered

stamps are not received by the distributor, the distributor remains liable for the balance due on this invoice and any demand or claim against the State

of Connecticut by the distributor for refund or credit of the amount paid for the ordered stamps is waived and released.

Signature of authorizing ofﬁ cer

Print name and phone number

If you need additional information or assistance, call the Registration Section at 860-297-5770, Monday through Friday, 8:30 a.m. to 4:30 p.m. Charge

customers who wish to have their order shipped may fax the order to DRS at 860-297-4818 by 1:00 p.m. for same day processing.