Fillable Form Tc-564 - Tobacco/cigarette Tax Refund Request printable pdf download

Form Tc-564 - Tobacco/cigarette Tax Refund Request

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Utah State Tax Commission

210 N 1950 W • Salt Lake City, UT 84134 •

TC-564

Tobacco/Cigarette Tax Refund Request

Rev. 9/11

Name of business entity

Street address (physical location)

City

State

ZIP Code

Mailing address

City

State

ZIP Code

Contact person last name

Contact’s first name

Middle initial

Contact’s phone number

Contact’s email

FEIN

Utah tobacco account number

A. Cigarette Stamp Refund Request

Reason for request (mark one)

 Stamps were destroyed (attach affidavit)

 Stamp return — stamps became obsolete (must return stamps) . . . . . . . . . . Roll number(s): ______________

 Stamp return — entity stopped doing business (must return stamps) . . . . . . Roll number(s): ______________

 Nontaxable sales to members of the Ute Tribe (attach exemption documentation)

Stamp refund calculation:

Stamp Type

Quantity

Stamp Value

Gross Refund

Discount

Net Refund

(Gross Refund minus Discount)

1. PM 20 pack

x $1.70 = $

x .04 =

2. PM 25 pack

x $2.125 = $

x .04 =

3. NPM 20 pk

x $2.05 = $

x .04 =

A Total stamp refund request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A

B. Cash Bond Refund Request

Reason for request (mark one):

 I am no longer a tobacco distributor

 I am no longer a stamper

 I am submitting a surety bond to replace a cash bond

 The above entity stopped doing business, effective (date): _ ___ ___ ___ ___ ___

B Total bond refund requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B

C. Total refund requested (add line A and line B)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C

Under penalty of falsification, I declare that, to the best of my knowledge, all the information in this Request and any

attached documentation is true and complete.

______ _ __ __ __ _____ __ _ _ _ _ __ _ _ _

_ _ _ _ __ _ _ _ _________

______________

_______ _________

Authorized Signature

Title

Date

Telephone