Form Ct-4eft - Eft Fax Confirmation

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Indiana Department of Revenue
Fax Confirmation to: (317) 615-2691
E-mail confirmation to:
Special Tax Division
Form CT-4EFT
INCigTax@dor.in.gov
Questions? (317) 615-2710
EFT FAX Confirmation
State Form 53625
(R3 / 10-11)
This confirmation must be faxed the day the
FAX
transaction is originated.
Attn: Special Tax Division - Cigarette Tax
From:
Number of Pages:
Date:
This fax is to confirm information pertaining to our company’s most recent EFT tax stamp payment. Contact information
is provided below if the Department of Revenue should have any questions. Please include a copy of the invoice. Please
type or print.
Name of Company:
Cigarette License Number:
Invoice Number:
Transaction Amount:
Transaction Date:
Invoice Due Date:
Contact Name:
Contact Phone:
Contact Title:
Confidentiality Notice
This telecopy and any documents accompanying it contain confidential information (IC 6-8, 1-7-1) belonging to the sender
which is legally privileged. This information is intended only for the use of the individual(s) or entity named above. Please
handle these document in strictest confidence. If you are not the intended recipient, you are hereby notified that any
disclosure, copying, distribution, or taking any action in reliance on the contents of this telecopied information is strictly
prohibited. If you have received this telecopy in error, please notify the Department of Revenue immediately by telephone
at (317) 615-2710 to arrange for return of the documents.Thank you in advance for your cooperation.

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