Form 1049c-9602 - Claim For Revision License Tax - 2013
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12013
STATE OF DELAWARE
Department of Finance
Division of Revenue
CLAIM FOR REVISION
820 N. French Street
REV CODE 0035-42
LICENSE TAX
P.O. Box 2340
Wilmington, Delaware 19899-2340
FORM 1049C-9602
THIS FORM TO BE USED TO CLAIM
CIGARETTE EXCISE TAX REFUNDS
1.
Enter Account Number
_ _
_ _
2.
Business Code Group Description
3.
Business Name
4.
Trade Name if Different from Above
5.
Business Location Address
6.
Mailing Address if Different
City
State
Zip Code
City
State
Zip Code
Delaware excise tax stamped stale, damaged or unusable cigarettes were returned to manufacturer(s) in the quantities
and package configuration listed below as evidenced by the enclosed notarized statement(s) from manufacturer(s).
packages of 20 cigarettes @ $1.60 cents per pack = $
packages of 25 cigarettes @ $2.00 cents per pack = $
$
TOTAL AMOUNT TO BE REFUNDED:
SIGNATURE
TITLE
DATE
I declare under penalties as provided by law that the information on this application is true, correct and complete.
*DF40013019999*
Revised 01/14/13
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Parent category: Financial