CT109A
Distributor Affidavit
Application for credit memo for damaged cigarette tax stamps.
Name
Minnesota Tax ID Number
Street
City
State
ZIP Code
I,
, hereby state I am an authorized agent of
.
On the
day of
20
, I counted misapplied and/or damaged stamps as follows:
Number of cigarettes per pack
20s
25s
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Affixed to carton end flaps
Additional stamps per pack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Returned stamps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Partial stamps (which were restamped) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total credit requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I further state that only misapplied/damaged stamps were included in the above count, and that a credit memo has not been previ-
ously requested for the same stamps.
State of
, county of
.
Subscribed and sworn to before me on this
day of
20
,
at
.
NOTARY PUBLIC
Mail to Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331.
Phone: 651-556-3035. Fax 651-556-5236. Email: cigarette.tobacco@state.mn.us
(Rev. 7/17)