Form Cg-25 - Order Form For Cigarette Tax Indicia

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CG-25
KANSAS DEPARTMENT OF REVENUE
(Rev. 6/13)
915 SW Harrison
Topeka, Kansas 66612-1588
ORDER FORM FOR CIGARETTE TAX INDICIA
FOR OFFICE USE ONLY
Trade Name
Invoice No. __________________________________
Street Address
Date Issued
__________________________________
City, State, Zip
Stamp No. ___________________________________
Date Ordered
Charge Purchase
Cash Purchase
# of Rolls
Gross Amount
Discount .80%
Net Amount
Fed Ex
Fuson - 20s
Fuson - 25s
Account Number
UPS
Total Due
Signature ___________________________________

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