Form Cig50021 - Order Blank Oklahoma Cigarette Tax Stamp

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Form CIG50021
Revised 10-2011
Order Blank
CIG
Oklahoma Cigarette Tax Stamp
Date of Order
Firm Name
FEI/SSN
Cigarette License Number
Shipping Address
Contact Person
Telephone
Shipping City, State, Zip
Email
Fax
Format
Color
Type
Number of Stamps
Tax Rate
Denominations
Tax Due
30,000 per roll
$
Green
$1.0300
Roll
A
(20-pack)
150 per sheet
$
Green
$1.2875
Sheet
B
(25-pack)
150 per sheet
$
Green
Sheet
$1.0300
C
(20-pack)
$
1.
Total Gross Value
Discount Calculation
$(
)
2a.
Total Stamps
2b.
Less: $0.015 per stamp
$
3.
Total Remittance
Shipping Carrier and Account Number
Shipping Billing Number
4a.
4b.
Acknowledgment
For OTC/Bank Purposes Only
Name/Address
Beginning Roll Number
Ending Roll Number
Type Quantity
Agent
Signature
Date
Printed Name
Signature
Date
Bring your completed order blank to our physical address:
Mail completed order blank with your remittance to:
Oklahoma Tax Commission
Oklahoma City:
Tulsa:
Connors Building - 1st Floor Cashier
Kerr State Office Building - 5th Floor
Attn: Cigarette Tax Stamp Order
Post Office Box 269060
2501 North Lincoln Boulevard
440 South Houston, Suite 501B
Oklahoma City, OK 73126-9060
Oklahoma City, OK 73105
Tulsa, OK 74127

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