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					                               South Dakota Cigarette Stamp Order Blank & Receipt Form
 Revised 06/07                                       South Dakota Department of Revenue & Regulation
                                                445 E. Capitol Avenue | Pierre, SD 57501-3185 | 1-800-TAX-9188

Part I Information
TD Li cense Number                                                     D ate                                     Telephone Number

D i stri butor's Name

Mai li ng Address

C i ty                                                                 State                                     Zi p C ode

Part II Order Form
               Type of Stamps        Stamps per Uni t               Rate per Uni t            Uni ts Requested                Value of Stamps

            A-heat appli ed
 Packs of

                                   150 per sheet                $               229.50 x                                  =$
            (10 x 15 sheets)

  Part I B-heat applied            30,000 per roll              $           45,900.00 x                                   =$
 Packs of

            C -heat appli ed

                                   150 per sheet                $               288.00 x                                  =$
            (10 x 15 sheets)

Make Remittance payable to the SD State Treasurer or the                Total Value of Stamps                             $ ________________
SD Department of Revenue & Regulation
                                                                        Less 2% discount                                  $ ________________
                                                                        Subtotal                                          $ ________________
  Distributor will be billed for the cost of heat applied to            Less Credit Memo #                                $ ________________
  stamp paper.
                                                                        Total Amount of Remittance                        $ ________________

Signature of Distributor or Authorized Agent _________________________________________________________________

     Part III Receipt           For Department of Revenue & Regulation Use Only
            Type of Stamp                 # of Uni ts i ssued                              Seri al Numbers of stamps i ssued

                                                       Total Amount of Remittance received                $ _______________________

Signature of Authorized Issuing Agent ____________________________ Date ____________________________________

Signature of person receiving stamps (if physical delivery) ______________________________________________________

Part IV Receipt
Distributor completes Part I & II - keeping the pink copy for their records.
SEND THE WHITE AND YELLOW COPY TO:                     SD Department of Revenue & Regulation
                                                       Special Tax Division
                                                       445 East Capitol Avenue
                                                       Pierre, SD 57501-3185
WHITE COPY - SD Department of Revenue & Regulation           YELLOW COPY - DRR - to be returned with stamps                   PINK COPY - Licensee

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