Form 0405-620 - Cigarette Tax Stamp Order Form
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Alaska
620
Cigarette Tax Stamp Order Form
License Number(s)
Period Ending (Year/Month)
AK Business License Number
EIN
SSN
Business Name
Telephone Number
Fax Number
Mailing Address
Contact Person
Contact Telephone Number
City
State
ZIP Code
Contact Email
Payment is due at the time of order unless you are approved for deferred payment. Payment must be in the form of a certified check,
cashier’s check or U.S. Postal Money Order made payable to “State of Alaska”; by wire transfer, or by using the Online Tax Information
System (OTIS), the Department of Revenue’s Online Payment service. In special circumstances, the department will accept a company
check (see instructions).
Electronic Payment Information
Note: If your liability exceeds $100,000 you must pay using the Online Tax Information System (OTIS) at or by wire transfer.
Check if you are paying by:
OTIS (confirmation #
)
Wire transfer (date
)
Check here if you are paying under a deferred payment plan. See instructions for information. If payment is authorized under a
deferred payment plan, payment is due by the end of the month following the month the stamps were ordered.
Filling of Stamp Orders. For those paying under a deferred payment plan, stamp orders will be filled within the same business day
provided the order is received before 10 a.m. Alaska Standard Time (AST). For all others, stamp orders will be filled once verification
of funds has been received by the Tax Division (see instructions).
Stamp Order and Calculation
PM cigarettes
NPM cigarettes
PM cigarettes
20 cigarettes/pack
20 cigarettes/pack
25 cigarettes/pack
of Cigarette Tax Due
See page 1 of the instruction for definitions
Machine stamp rolls
Hand-applied stamps
Hand-applied stamps
Hand-applied stamps
of PM and NPM cigarettes.
(15,000 per roll)
(lots of 150 stamps)
(sheets of 150 stamps)
(sheets of 150 Stamps)
1
Type and quantity of stamps
1
15,000
150
150
150
2
Number of rolls, lots or sheets
2
3
Total stamps. Multiply line 1 by line 2
3
4
Value of each stamp
4
$ 2.00
$ 2.00
$ 2.25
$ 2.50
5
Tax. Multiply line 3 by line 4
5
$
$
$
$
6
Cigarette tax due. Add the total of all columns in line 5
6
$
7
Cigarette tax paid with order
7
$
Signature of Licensee, Agent, or Designee
Date
Printed Name
Title
Pay online at or make check payable to State of Alaska
Stamp Order
Date Filled
Funds
Filled by
Checked by
Funds Verified by
Date
Batch #
Receipt #
Order #
620
Mail to: Alaska Department of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
0405-620 Rev 08/12
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