Form Aff-1 - Merchant'S Affidavit For Delivery Sales Of Cigarette And Tobacco Products

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Indiana Department of Revenue
AFF-1
Please mail form to:
Indiana Department of Revenue
State Form 51416
Merchant’s Affi davit for Delivery
(R2/05-07)
P.O. Box 901
Sales of Cigarette and Tobacco Products
Indianapolis, IN 46206-0901
Merchant Name
Telephone Number
Federal FEIN or SSN
Address
TID (if Applicable)
City
State
Zip Code
Principal Place of Business (
)
if different from above
List the name(s) and address of each place of business in Indiana
Responsible Offi cer (Please print)
Date
This affi davit is required to be fi led in accordance with IC 24-3-5-6(a) which requires a merchant making a delivery sale of cigarettes
or other tobacco products to notify the Department before making any delivery sale into Indiana.
A delivery sale is defi ned in IC 24-3-5-1 as: A transaction for the purchase of tobacco products in which an offer to purchase
tobacco products is made:
(1) electronically using a computer network (as defi ned in IC 35-43-2-3);
(2) by mail; or
(3) by telephone;
and acceptance of the offer results in delivery of tobacco products to a named individual at a designated address.
For questions related to this form call (317) 615-2564 or (317) 615-2561.

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