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Cigarette Tax Stamps Order Form - Form 73A404

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Cigarette Tax Stamps Order Form - Form 73A404 Powered By Docstoc
					73A404 (4-09)
Commonwealth of Kentucky DEPARTMENT OF REVENUE

CIGARETTE TAX STAMPS ORDER FORM

FOR DEPARTMENT USE ONLY

1 6 __ __ __ __ __ __ /__ __ / __ __ / __ __
Account Number Tax Mo. Yr.

Submit in Duplicate Name and Address of Wholesaler Date _______________________ , 20 _____ License No. ___________________________ Phone No. ____________________________ Email Address _________________________
20 CIGARETTES PER PACKAGE
Quantity Ordered Gross Value of Tax Evidence

Cost Each

1. Quantity Ordered and Cost: a. Sheet Stamps (150 stamps per sheet) b. Roll Stamps (30,000 stamps per roll) _____________ x $ _____________ x $ 90.00 18,000.00 = $ _____________ = $ _____________

Office Use Only Beg. End.

2. Gross Values of 20 Pack Stamps (add lines 1a and 1b) ...................................................................................................................... $ ______________

25 CIGARETTES PER PACKAGE
Quantity Ordered Gross Value of Tax Evidence

Cost Each

3. Quantity Ordered and Cost: a. Sheet Stamps (150 stamps per sheet) b. Roll Stamps (4,800 stamps per roll) c. Roll Stamps (12,000 stamps per roll) _____________ x $ _____________ x $ _____________ x $ 112.50 3,600.00 9,000.00 = $ _____________ = $ _____________ = $ _____________

Office Use Only Beg. End.

4. Gross Values of 25 Pack Stamps (add lines 3a, 3b and 3c) ............................................ .................................................................... $ ______________ TOTAL DUE COMPUTATION 5. 6. 7. 8. 9. 10. Gross Values of all Stamps (add lines 2 and 4) Gross Excise Tax Due (multiply line 5 by 0.05) Compensation on Excise Tax (multiply line 6 by .0909) if applicable Net Excise Tax Due (line 6 minus line 7) Surtax Due (multiply line 5 by 0.45) 2009 Surtax Due (multiply line 5 by 0.50) $ $ $ $ $ $ _____________ _____________ Credit _____________ Certificates _____________ – $ ______________ _____________ – $ ______________ _____________ – $ ______________

= = =

01 02 06

$ _____________ $ _____________ $ _____________

11. Total Amount Due (add lines 8, 9 and 10)............................................ .............................................................................................. $ ______________ ➤ Make check(s) payable to Kentucky State Treasurer. Send Orders To: Kentucky Department of Revenue Cigarette Tax Stamp Unit PO Box 138 Frankfort, KY 40602-0138 Special Shipping Instructions Overnight Address 501 High Street Frankfort, KY 40601

Purchase made from _____________________________________________ Date ______________________
Department of Revenue Office

Order Filled and Approved by _________________________________________________________________
Full Name

Questions concerning Cigarette Tax Stamp orders should be directed to the above address or (502) 564-5395.


				
DOCUMENT INFO
Description: Kentucky Tobacco Tax Forms