Form Ct109a - Distributor Affidavit

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Distributor Affidavit
CT109A
Application for credit memo for damaged cigarette tax stamps.
Name
Minnesota tax ID number
Street
City
State
Zip code
I,
, hereby state I am an authorized agent of
.
On the
day of
20
, I counted misapplied and/or damaged stamps as follows:
Number of cigarettes per pack
20s
25s
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Affixed to carton end flaps
Additional stamps per pack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Returned stamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Partial stamps (which were restamped) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total credit requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I further state that only misapplied/damaged stamps were included in the above count, and that a credit memo has not been
previously requested for the same stamps.
State of
, county of
.
Subscribed and sworn to before me on this
day of
20
,
at
.
NOTARY PUBLIC
Tel: 651-556-3035
Special Taxes Division
Mail Station 3331
Fax: 651-297-1939
St. Paul, MN 55146-3331
Minnesota Relay (TTY) 711
An equal opportunity employer
(Rev. 7/10)

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