Form Cg-114-E - Expedited Claim For Refund For Indian Tax-Exempt Cigarette Sales Page 2

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CG-114-E (4/11) (back)
Prior approval sales
Reporting confirmation number
Purchaser’s name
For auditor’s use only
Amount allowed: $
Audited by
(Examiner)
(Date)
Approved for payment:
Audited by
(Tax technician)
(Comptroller)
(Date)
For office use only
Mail your claim form and any related attachments to:
NYS TAX DEPARTMENT
TDAB FACCTS - CIGARETTE TAX UNIT
W A HARRIMAN CAMPUS
ALBANY NY 12227

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