Form 73a404 - Cigarette Tax Stamps Order Form
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173A404 (4-11)
FOR DEPARTMENT USE ONLY
Commonwealth of Kentucky
CIGARETTE TAX STAMPS
DEPARTMENT OF REVENUE
__ __ __ __ __ __ /__ __ / __ __ / __ __
1 6
ORDER FORM
Account Number
Tax
Mo.
Yr.
Submit in Duplicate
Name and Address of Wholesaler
Date _______________________ , 20 _____
License No. ___________________________
Phone No. ____________________________
Email Address _________________________
20 CIGARETTES PER PACKAGE
Quantity
Gross Value of
Ordered
Cost Each
Tax Evidence
Office Use Only
1. Quantity Ordered and Cost:
Beg.
End.
a. Sheet Stamps (150 stamps per sheet)
_____________ x $
90.00
= $ _____________
b. Roll Stamps (30,000 stamps per roll)
_____________ x $
18,000.00
= $ _____________
2. Gross Values of 20 Pack Stamps (add lines 1a and 1b) ...................................................................................................................... $ ______________
25 CIGARETTES PER PACKAGE
Quantity
Gross Value of
Ordered
Cost Each
Tax Evidence
Office Use Only
3. Quantity Ordered and Cost:
Beg.
End.
a. Sheet Stamps (150 stamps per sheet)
_____________ x $
112.50
= $ _____________
b. Roll Stamps (4,800 stamps per roll)
_____________ x $
3,600.00
= $ _____________
c. Roll Stamps (12,000 stamps per roll)
_____________ x $
9,000.00
= $ _____________
4. Gross Values of 25 Pack Stamps (add lines 3a, 3b and 3c) ............................................ .................................................................... $ ______________
TOTAL DUE COMPUTATION
5. Gross Values of all Stamps (add lines 2 and 4)
$ _____________
6. Gross Excise Tax Due (multiply line 5 by 0.05)
$ _____________
Credit
Certificates
7. Compensation on Excise Tax (multiply line 6 by .0909) if applicable $ _____________
8. Net Excise Tax Due (line 6 minus line 7)
$ _____________ – $ ______________
=
01
$ _____________
9. Surtax Due (multiply line 5 by 0.45)
$ _____________ – $ ______________
=
02
$ _____________
10. 2009 Surtax Due (multiply line 5 by 0.50)
$ _____________ – $ ______________
=
06
$ _____________
11. Total Amount Due (add lines 8, 9 and 10)............................................ .............................................................................................. $ ______________
➤ Make check(s) payable to Kentucky State Treasurer.
Send Orders To:
Special Shipping Instructions
Kentucky Department of Revenue
Cigarette Tax Stamp Unit
Overnight Address
PO Box 138
501 High Street
Frankfort, KY 40602-0138
Frankfort, KY 40601-2103
Purchase made from _____________________________________________ Date ______________________
Department of Revenue Office
Order Filled and Approved by _________________________________________________________________
Full Name
Questions concerning Cigarette Tax Stamp orders should be directed to the above address or (502) 564-5395.
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