Form 610r - Claim For Refund Of Overpayment Of Other Tobacco Products Floor Tax
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1CLAIM FOR REFUND OF
FORM
610R
OVERPAYMENT OF OTHER TOBACCO
PRODUCTS FLOOR TAX
Date: ____________________________
Claim for tax refund is hereby made in the amount of $ _________________________ .
This claim is itemized as follows:
Our reasons for filing claim are:
Name of Company _______________________________________________________________________________________________________
Street Address __________________________________________________________________________________________________________
City ______________________________________________________________State __________ Nine Digit Zip Code ____________________
Federal Identification #
CR#
Complete this Claim For Refund and send to:
Comptroller of Maryland
Revenue Administration Division
Other Tobacco Tax
P.O. Box 2999
Annapolis, Maryland 21404-2999
For more information, contact:
410-260-7980/1-800-638-2937
Fax# 410-974-3608
AFFIDAVIT
I do solemnly declare and affirm under the penalties of perjury that the contents of the foregoing document are true and correct to
the best of my knowledge, information, and belief.
Signature
Title
COM/ATT-610-5
Revised 06/12
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