Form Ct-4a - Indiana Cigarette Tax Stamp Order
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1CT-4A
Indiana Cigarette Tax Stamp Order
For Offi ce Use Only
State Form 46862
If you have questions about this form
Inv. Number:
(R6 / 10-12)
please call (317) 615-2710. Orders may
be mailed to the address at the bottom of this form,
Invoice Date:
CIG License # ________________________
emailed to INCigTax@dor.in.gov
CIG# Exp. Date:
or faxed to (317) 615-2691.
Date: _________________________
Description
Serial Numbers
Processed By
Rolls of 30M 99.5¢ Stamps, 20 Cigarettes
_____________________________________
_________________
Price
Amount
1.
Enter number of rolls (30,000 stamps per roll) ................................................................................ _______ X $29,850 per roll
______________
Enter number of stamps ..........................................................................................
Description
Serial Numbers
Processed By
Sheets of 150 99.5¢ Stamps, 20 Cigarettes (WIDES)
_______________________________________
_________________
Price
Amount
2.
Enter number of sheets (150 stamps per sheet) ............................................................................. _______ X $149.25 per sheet _____________
Enter number of stamps ..........................................................................................
Description
Serial Numbers
Processed by
Fuson Stamps, 99.5¢ per stamp, 20 Cigarettes
_______________________________________
_________________
Price
Amount
3.
Enter number of stamps (number must be divisible by 300) ........................................................... _______ X $0.995 per stamp ______________
Enter number of stamps ..........................................................................................
Description
Serial Numbers
Processed by
7200T, $1.24375 Stamps, 25 Cigarettes
_______________________________________
_________________
Price
Amount
4.
Enter number of rolls (7200 stamps per roll/10 stamps per row) .................................................... _______ X $8,995 per roll
______________
Enter number of stamps ..........................................................................................
Description
Serial Numbers
Processed by
7200M, $1.24375 Stamps, 25 Cigarettes
_______________________________________
_______________
Price
Amount
5.
Enter number of rolls (7200 stamps per roll/12 stamps per row) .................................................... _______ X $8,995 per roll
______________
Enter number of stamps ..........................................................................................
6.
Total number of stamps ordered
7.
Add tax from lines 1 through 5 .......................................................................................................................... Gross Tax Total
______________
8.
Multiply $0.012 X total number of stamps from line 6 ...................................................................................................Discount
______________
9.
Subtract line 8 from line 7 ....................................................................................................................................... Net Tax Total
______________
10. Bad Debt Credit (Please attach necessary forms) .........................................................................................................................
______________
11. Subtract line 10 from line 9 ...................................................................................................................................................Total
______________
Description
Serial Numbers
Processed by
Cigarette Papers: $12 per 100 sheet (no discount)
_______________________________________
_______________
Price
Amount
12. Enter number of sheets ..................................................................................................................... _______ X $12 per sheet
______________
13. Shipping (UPS Ground) - Leave blank if you are using your account to ship. .............................................................................
______________
14. Add lines 11, 12 and 13 ......................................................................................................................................... Total Amount
______________
_________________________________________________________
Indicate Payment Method:
□
□
Name of Company
Payment Enclosed
Authorized 30 Day Credit
_________________________________________________________
Shipping Address
Shipping Options:
_______________________________ ____________
___________
City
State
Zip Code
If you wish to use your company’s shipping account please enter the ac-
count number below and specify service you wish to use (e.g. UPS Next
_________________________________________________________
Day Air, or FedEx Priority Overnight).
Name, Title and Telephone Number (direct or include ext number)
of Authorized Purchaser
________________________________ _________________________
FedEx Account Number
Service
Mail to:
Overnight or Certifi ed Mail:
Indiana Department of Revenue
Indiana Department of Revenue
________________________________ _________________________
UPS Account Number
Service
Attention: Cigarette Tax
Attention: Cigarette Tax
P.O. Box 901
7811 Milhouse Road, Suite P
Indianapolis, IN 46206-0901
Indianapolis, IN 46241-9612
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