CIG 51
Rev. 3/09
Reset Form
Dealer’s Account Number
P.O. Box 530
Columbus, OH 43216-0530
94-
Claim for Reimbursement of Cigarette Tax
Dealer’s Claim Number
(Dealer to Complete for Tracking)
Illegally or Erroneously Paid and/or
Unused Cigarette Tax Stamps
State File Number
For the period from
, 20
to
, 20
, inclusive.
1. Name
Print name of dealer as shown on dealer’s license
2. Address
Street
City
State
ZIP code
3.
If records are located at an address other than line 2, show on line 3.
4. Federal employer identifi cation number or, if none assigned for
Social Security number
Federal identifi cation number
reporting federal taxes, please enter your Social Security number.
5. By an illegal or erroneous payment or assessment ....................................................................... $
If claim is based on cigarettes returned to the manufacturer thereof, state total number of such cigarettes with tax
stamps affi xed and total tax amount:
6. State only stamped............
x
.0625
=
$
7. Less dealers discount (line 6 x .018) .............................................. =
8. Net amount (line 6 minus line 7) ..................................................................................................... $
9. Combined stamped............
x
.07975
=
$
10. Less dealers discount (line 9 x .018) .............................................. =
11. Net amount (line 9 minus line 10) ................................................................................................... $
12. County only stamped .........
x
.01725
=
$
13. Less dealers discount (line 12 x .018) ............................................ =
14. Net amount (line 12 minus line 13) ................................................................................................. $
If claim is for unused tax stamps, indicate quantity and total face value below.
Unused State Stamps
15. 20 stamps ..........................
x
1.25
=
$
16. 25 stamps ..........................
x
1.5625
=
17. Total of lines 15 and 16...................................................................
18. Less dealers discount (line 17 x .018) ............................................ =
19. Net amount (line 17 minus line 18) ................................................................................................. $