Form 0405-623 - Application To Purchase Cigarette Tax Stamps On Deferred Payments Basis
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Alaska
623
Application to Purchase Cigarette
Tax Stamps on Deferred Payments Basis
License Number
License Period
AK Business License Number
EIN
SSN
Name
Phone Number
Fax Number
Mailing Address
Contact Person
Contact Telephone Number
City
State
ZIP Code
Contact Email
As provided in Alaska Statute 43.50.550(b), the undersigned, duly licensed by the State of Alaska Under AS 43.50.010 or AS 43.50.035,
herby applies to purchase cigarette tax stamps on a deferred payment basis in an amount not to exceed $ _____________________
in any one calendar month.
This application is accompanied by a surety bond executed by a corporation incorporated under the laws of the State of _______________
and authorized to engage in business as surety company in Alaska.
Attach completed form 041D, Cigarette Tax Surety Bond.
Name of Surety Company
Bond Number
City
State
ZIP Code
Amount of Bond
Note: Amount of bond must equal 200 percent of the maximum dollar amount of allowed monthly cigarette stamp purchase.
Date
Signature of Taxpayer or Representative
Title
Printed Name and Title of Taxpayer or Representative
FOR DEPARTMENT USE ONLY
Application to purchase cigarette tax stamps on a deferred payment basis approved in the amount of
$
Application to purchase cigarette tax stamps on a deferred payment basis denied.
Approved By:
Title
Date
If approved, the above-named licensee may purchase cigarette tax stamps on a deferred payment basis until this date
623
Mail to: Alaska Department of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
0405-623 Rev 08/12
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Parent category: Financial