Form Ct-3 - Vermont Cigarette Tax Stamp Order
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1VERMONT CIGARETTE TAX STAMP ORDER
VERMONT DEPARTMENT OF TAXES
133 State Street
PO Box 547
Montpelier, VT 05601-0547
Telephone: (802) 828-6839
Name and Address of Purchaser
Date
Federal ID Number
COST OF EACH
QUANTITY
ITEM
DENOMINATION
as of 07/01/2011
TOTAL COST
Roll of 30,000
20 Cigarette
$76,792.20
$
Sheet of 600
20 Cigarette
$1,535.84
$
Roll of 7,200
25 Cigarette
$23,037.66
$
Sheet of 600
25 Cigarette
$1,919.81
$
TOTAL AMOUNT REMITTED
$
Stamp price is $2.62 per pack of 20, and $3.275 per pack of 25, minus 2.3% prepayment discount.
Method of Payment
(check one)
CHECK
Check #: __________________ Date: __________________ Amount: $_________________
Package Tracking #: _____________________________________
Shipping Company: _____________________________________
ELECTRONIC FUNDS TRANSFER
EFT Transaction Date: __________________ Amount: $_________________
(802) 828-5787
FAX order to:
OR
Mail to: Vermont Department of Taxes
Miscellaneous Tax Division
133 State Street
PO Box 547
Montpelier, VT 05601-0547
If you have any questions, please call (802) 828-6839.
FOR DEPARTMENT USE ONLy
Order filled by
Date
Received by
Date
Date sent
via
Form CT-3
Rev. 02/12
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