Form Tc-79 - Cigarette Revenue Stamps Order Form
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1
2Utah State Tax Commission
210 N 1950 W • SLC, UT 84134 •
TC-79
Cigarette Revenue Stamps
Rev. 6/11
Order Form
Denomination or Description
Quantity
Unit Price Amount Due
Office Use Only
Small Orders 1. 20 count stamps – multiples of 240
$408.00
2. 20 count NPM stamps – multiples of 150
$307.50
Roll Orders
3. 20 count rolls – 30,000 stamps
$51,000.00
4. 20 count NPM rolls – 15,000 stamps
$30,750.00
5. 25 count rolls – 7,200 stamps (M-12 across)
$15,300.00
6. 25 count NPM rolls – 7,200 stamps
$18,450.00
7.
Subtotal (Add lines 1 through 6. Discount applies to this subtotal.)
$
Date filled
8.
Discount (Multiply line 7 by .04)
9.
Net Tax (Line 7 minus line 8)
Order filled by:
Delivery Instructions
Check one:
Will call
Special Handling
Carrier: _____ ____ ____ _ ____ ________ ___ _
Carrier Account number: _ ___ _ _ _ _ _ _ _ _
Deliver stamps to (enter name):__ ____ ________ ___ ___ ___ ___ ___ ___ __ ___ _ _ _ _ _ _ _ _
Enter delivery address, if different than below:_______ __ ___ ___ ___ ___ ___ ___ ___ __ _ _ _ _ _ _
Signature of person receiving stamps: ___ _______ ___ ___ ___ ___ ___ __ Date: ___ _ _ _ _ _ _ _ _
License Holder Information
Name:
__ _______ ____ ____ _ ____ _____ ___ __ Account number: ___ ___ ___ __ _ _ _ _ _ _ _
Address:
___________________________________________________________
City:
___ __________ ____ _____ _______ _
State:
__ ___ _
ZIP Code:
______________
Contact Person
Name:
__ _______ ____ ____ _ ____ ____
Email address: _________________________
Signature
If this order is purchased on credit, the license holder agrees to pay the total amount due within 60 days of the date filed.
____ __ _________ ____ ____ _ _______
_ __ ___ ___ _____
________________
License holder
Phone
Date
Mail or deliver this order form to:
Cigarette Stamps
Amount Paid
Utah State Tax Commission
210 North 1950 West
Salt Lake City, UT 84134
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