Tax Stamp Order Form
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1Marijuana and Controlled Substance
Iowa Department of Revenue
Tax Stamp Order Form
Name:
Address:
City,State,Zip:
OFFICE USE ONLY
(B)
(A)
Tax Rate
(A X B)
Number of
Number of Plants
per Plant
Tax Due*
Stamp Sequence
Stamps
Marijuana Plants
$750.00
(A)
(B)
(C)
Weight of Each
Number of
Tax Rate
(A X B X C )
Number of
Package (grams)
Packages
per Gram
Tax Due*
Stamp Sequence
Stamps
Marijuana
$5.00
(A)
(B)
(C)
Weight of Each
Number of
Tax Rate
(A X B X C)
Number of
Package (grams)
Packages
per Gram
Tax Due*
Stamp Sequence
Stamps
Controlled Substance
$250.00
By Weight
(A)
(B)
Quantity per
Number of
(C)
(A X B X C)
Number of
Package
Packages
Tax Rate
Tax Due*
Stamp Sequence
Stamps
Controlled Substance
$400.00 / 10
By Dosage
Date of Sale:
_______ /_______/_______
Total Amount Due:
$
*Payment will be accepted in the form of cash, certified check, or money order. No personal checks will be accepted.
*You are not required to give your name, address, or any other identifying information; however if you are ordering by mail,
you must provide a valid mailing address for shipping.
*Stamps ordered by mail will be mailed first class at the risk of the purchaser.
*The minimum purchase price for a single stamp transaction is $215.00 or more (701 IAC 91.2)
*Mailing Address:
Iowa Department of Revenue-Taxpayer Services
PO Box 10457
Des Moines, IA 50306-0457
70-510 (8/13)
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Parent category: Medical