Cigarette Tax Stamps Order Form printable pdf download

Cigarette Tax Stamps Order Form

Town of Warsaw

PO Box 730

78 Belle Ville Lane

Warsaw, VA 22572

(804) 333-3737

CIGARETTE TAX STAMPS ORDER FORM

Applicant: ____________________________________________________________

Mailing Address:

______________________________________________________

Federal Tax Identification Number: ________________________________________

Signature: ____________________________________________________________

The above applicant hereby applies to Susan M. Pemberton, Town Treasurer for

the following number of rolls of Warsaw cigarette tax stamps:

Number of rolls________@ 15,000 stamps per roll = ______________ stamps

Amount of stamps requested

=_______________ stamps

NUMBER OF STAMPS @ 0.25 PER PACK = $ ______________________

Less discount of 6/1000 of a cent per stamp

per face value thereof = $ ______________________

TOTAL TAX DUE

= $ ______________________

OFFICE USE ONLY:

Approved by Susan M. Pemberton

Treasurer – Town of Warsaw

___________________________________

Date:

___________________________________

Roll Number:

___________________________________

Date Payment received: _____________

Amount received: ___________________

Date picked up: ____________________

Date mailed: ________________________

Signature: (Authorized company representative) ________________________________

Cigarette Tax Stamps Order Form