Form Boe-663-Acts - California Cigarette Tax Stamp Purchase Order

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BOE-663-ACTS (FRONT) REV. 4 (4-13)
STATE OF CALIFORNIA
CALIFORNIA CIGARETTE TAX STAMP PURCHASE ORDER
BOARD OF EQUALIZATION
Please print or type - Instructions are available on the reverse of this form
BOE USE ONLY
DATE
Cigarette Tax Stamp
Program
MIC:41
DISTRIBUTOR’S ACCOUNT NUMBER
DATE ENTERED
CR STF 02­
DISTRIBUTOR’S NAME
ENTERED BY
BUSINESS ADDRESS (city, state, zip code)
ORDER NUMBER
ORDER FORM INSTRUCTIONS
A
B
C
D
E
TAX VALUE
STAMP DESCRIPTION
ROLL QUANTITY
VALUE PER ROLL
(C X D)
1. Large Roll of 20 denomination
30,000 stamps per roll valued
$ 26,100
(For high volume stamp machine)
at $0.87 for each stamp
2. Small Roll of 20 denomination
1,200 stamps per roll valued
$ 1,044
(For low volume stamp machine)
at $0.87 for each stamp
3. Small Roll of 10 denomination
1,200 stamps per roll valued
$
522
(For low volume stamp machine)
at $0.435 for each stamp
$ 1,305
4. Small Roll of 25 denomination
1,200 stamps per roll valued
(For low volume stamp machine)
at $1.0875 for each stamp
5.
Total Tax Value
This Order
6.
Less Discount
(0.0085 of line 5)
7.
Amount of order
(Line 5, less line 6)
$
SHIPPING OPTIONS (see instructions on reverse)
Standard
Expedite
PRINT NAME
USER ID NUMBER
AUTHORIZED SIGNATURE
TELEPHONE NUMBER
EMAIL ADDRESS
(
)
CRS1
CLEAR
PRINT

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