Form 623 - Maryland Cigarette Tax - Stamp Request

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MARYLAND CIGARETTE TAX
Form
623
STAMP REQUEST
Purchaser’s Name
Date
Address
City
State
9 Digit Zip code
E-mail address
License No.:
TW-
Check one
DO NOT USE SPACE BELOW
Cash Purchase
Credit Purchase
Purchaser’s Order No.: ______________
PLEASE FURNISH MARYLAND STATE CIGARETTE TAX STAMPS AS SPECIFIED BELOW:
(Machine applied stamps must be ordered in rolls of 30,000 stamps each.)
MACHINE APPLIED
SERIAL NUMBERS
QUANTITY
VALUE
DISCOUNT
NET AMOUNT
STAMPS
From
To
STATEWIDE
$2.00
$
$
$
MACHINE APPLIED STAMPS MUST BE ORDERED IN ROLLS OF 7,200 STAMPS EACH:
M-
STATEWIDE
$2.50
SERIAL NUMBERS
QUANTITY
HAND APPLIED STAMPS
VALUE
DISCOUNT
NET AMOUNT
From
To
HAND APPLIED (fuson) STAMPS MUST BE ORDERED ON PADS OF 7,500
STATEWIDE (fuson) $2.00
$
$
$
CREDIT NOS. USED
TOTALS: FOR ALL STAMPS ORDERED $
$
$
TOTAL AMOUNT OF CREDIT USED $
NET AMOUNT $
SHIPPING COST $
TOTAL AMOUNT DUE $
DO NOT SEND CURRENCY. Unless you have arranged credit and given bond, attach a certified check, cashier’s check or post office
money order for the net amount of this purchase payable to the Comptroller of Maryland.
Delivery: (check one)
Please Ship
Our Messenger
THIS ORDER WILL NOT BE FILLED UNLESS SIGNED. ALL SIGNATURES MUST AGREE WITH SIGNATURE CARD. ALL ORDERS SOLD
F.O.B. ANNAPOLIS, MARYLAND.
Official signature of purchaser: ________________________________________________________________________________
Order filled by: ____________________________ Delivered to: ________________________________ Date: _____________
Signature of persons receiving stamps
Contact Information:
COMPTROLLER OF MARYLAND
REVENUE ADMINISTRATION DIVISION
MOTOR-FUEL, ALCOHOL AND TOBACCO TAX UNIT
PO BOX 2999
ANNAPOLIS, MD 21404-2999
1-410-260-7382
1-800-638-2937
COM/RAD-623
13-49

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