Form Td-624 - Stock Transfer Tax Stamps Order Form
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1New York State Department of Taxation and Finance
For office use only
Division of the Treasury
Received date
Order number
Stock Transfer Tax
Reviewed by
Order filled by
Stamps Order Form
Check number
Check amount
Tax Law — Article 12, Section 280-a
Name of purchaser
Daytime telephone number
(
)
Mailing address (number and street or PO box)
City, State, ZIP code
New York State Stock Transfer Tax Stamps
Stamp denomination
Quantity per denomination
Dollar amount per denomination
Dollars
Cents
$
.01
.02
.04
.05
.08
.10
.20
.40
.50
.80
1.00
2.00
3.00
4.00
10.00
40.00
100.00
Totals
Please furnish stock transfer tax stamps as specified above.
Signature of purchaser
Date
Instructions
Mail this completed order form with a certified check, money order,
Your order, an original receipt, and Form MT-658, Application for
or cashier’s check payable in U.S. funds to Commissioner of
Rebate of Stock Transfer Tax by Stamp Purchaser, will be delivered
Taxation and Finance to:
by the U.S. Postal Service to the address indicated above. If you
prefer us to send your order by FedEx, complete a FedEx Airbill and
NYS DIVISION OF THE TREASURY
include your account number.
STOCK TRANSFER TAX STAMP UNIT
PO BOX 22119
ALBANY NY 12201-2119
Need help?
If you prefer to send your order and payment by FedEx, use the
following address instead:
Visit our Web site at
NYS DIVISION OF THE TREASURY
(for information, forms, and online services)
STOCK TRANSFER TAX STAMP UNIT
110 STATE STREET - 2ND FLOOR
ALBANY NY 12207
Corporation Tax Information Center:
(518) 485-6027
To order forms and publications:
(518) 457-5431
Text Telephone (TTY) Hotline
(for persons with hearing and
speech disabilities using a TTY):
(518) 485-5082
TD-624 (9/13)
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