Form 0405-622 - Transfer Of Cigarette Tax Stamps
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1Alaska
622
Transfer of Cigarette Tax Stamps
Part I - Information About The Licensee Transferring The Cigarette Tax Stamps
License Number(s)
Period Ending (Year/Month)
AK Business License Number
EIN
SSN
Name
Phone Number
Fax Number
Mailing Address
Contact Person
Contact Telephone Number
City
State
ZIP + 4
Contact Email
Part II - Information About The Licensee Receiving The Cigarette Tax Stamps
License Number(s)
Period Ending (Year/Month)
AK Business License Number
EIN
SSN
Name
Phone Number
Fax Number
Mailing Address
Contact Person
Contact Telephone Number
City
State
ZIP + 4
Contact Email
Part III - Transfer Of Cigarette Tax Stamps - See Instructions
Number Of
Number Of Stamps
Value Of Tax
Total Value Of Tax Stamps
Cigarettes Per
Serial Number(S) On Stamps
Transferred
Stamps
Transferred (C) X (D)
Stamp
(b)
(c)
(d)
(e)
(a)
20 (PM)
$2.00
25 (PM)
$2.50
20 (NPM)
$2.25
Reason For The Transfer
Signature Of Licensee Transferring The Cigarette Tax Stamps
Signature Of Licensee Receiving The Cigarette Tax Stamps
Printed Name
Printed Name
Title
Date
Title
Date
Department Use Only
Signature
Title
Date
Transfer of cigarette tax stamps approved
Transfer of cigarette stamps not approved
622
Mail to: Alaska Department Of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
0405-622 Rev 08/12
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