Form 73 - Cigarette Stamp Order
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1*0-0-1703-099*
*0-0-1703-099*
Wyoming Department of Revenue
Excise Tax Division
122 W. 25th Street, Herschler Bldg.
Cheyenne, Wyoming 82002-0110
Cigarette Stamp Order
Business Name: ___________________________________________ WY License Number: _________________________
Name the License Was Issued Under
Contact Person: ____________________________________________ Phone Number: _____________________________
Ship To Street: _____________________________________________ Fax: _ ______________________________________
City, State, ZIP: ________________________________________________________________________________________
Shipping Instructions:
Carrier & Type of Service ____________________________ Do You Want Shipment Insured? Yes____ No____
(Next Day Air, Priority, etc)
If yes, how much do you want
Account Number: ___________________________________ the shipment insured for?_____________________
Heat Fusion Stamps: (30,000 stamps to a roll, order in multiples of 30,000)
If you are not bonded, certified funds or
a wire transfer are required before the
Quantity of Stamps:
_____________________________
stamps will be shipped to you.
Value at $0.60 per Stamp: _____________________________
Less Your 6% Discount: _____________________________
Submit all orders and remittances to:
Less Credit Memo:
_____________________________
Amount of Remittance:
_____________________________
Wyoming Department of Revenue
Cigarette Tax Section 122 W 25th ST, 2W
____________________________________
________________
Cheyenne, WY 82002-0110
Authorized Signature
Date
Fax: 307-777-6975
Important Tax Information:
Cigarette stamps shall be sold by and purchased from the Wyoming Department of Revenue. The Department shall only sell
stamps to a licensed wholesale dealer. Stamps shall be sold to the wholesaler at a discount of 6% in rolls of 30,000.
Any package of cigarettes found in this state without Wyoming stamps, imprints or impressions affixed is considered
contraband goods and may be seized without a warrant by the Department.
Please note: Stamp orders shall not be filled for wholesalers who are out of compliance with any of our rules, including
but not limited to failure to file the monthly report by the 20th day of each month following the month of the cigarette
sales report period.
Form 73 – Revised 4/25/11
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