Form Ctx-Aw - Application For A Wholesale Cigarette License Or License To Operate Cigarette Vending Machines Page 5
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5NYC DEPARTMENT OF FINANCE
ENFORCEMENT DIVISION
W H O L E S A L E C I G A R E T T E L I C E N S E
G
A N N U A L A F F I D AV I T
TM
Finance
NYC Department of Finance, Enforcement Division, CTX Unit, 30-10 Starr Avenue, 2nd Floor, Long Island City, NY 11101
Instructions: This form to be submitted by sub-jobbers and vending machine operators who only purchase joint New York State /
New York City stamped cigarettes. Sub-jobbers and vending machine operators must file quarterly returns on Form CTX-R within
15 days after the end of each quarter (December - February, March - May, June - August, September - November). All others must
file monthly returns on Form CTX-R within 15 days after the end of the month.
License Number:_____________________________________________________
Applicant Name: ___________________________________________________________________________________________
}
Address:__________________________________________________________________________________________________
Number and Street
City:_______________________________________________________________ State: ________ Zip Code: ______________
STATE OF NEW YORK
S.S:
COUNTY OF
______________________________________________________________________________ , being duly sworn, deposes and says that he/she is
Name of Affiant
__________________________________________________________ of the ______________________________________________________
Title: Owner, Partner, or Officer
Name of Organization (Applicant)
Located at ______________________________________________________________________________________________________________
Address
That during the period indicated above the applicant will purchase only packages of cigarettes with joint New York State/New York City
Cigarette Tax stamps affixed thereto. In the event that packages of cigarettes are purchased without having affixed thereto joint New
York State/New York City Cigarette Tax stamps, the applicant will file a monthly Cigarette Tax Return within fifteen (15) days after the
close of the calendar month in which such purchases were made. Cigarette Tax Returns will be filed monthly thereafter.
______________________________________
Name of Applicant
______________________________________
Signature of Affiant
Sworn to before me this
______________ Day of __________________,20 ________
(Corporate Seal Must Be Affixed If Applicable)
__________________________________________________________
Signature and Title of officer administering oath
My Commission Expires __________________________. 20 ________________
Visit Finance at nyc.gov/finance
CTX-WD 07.15.11
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