Iowa 70-044 Cigarette Tax Stamp Order Form by cxb13183

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									                  Iowa Department of Revenue
                  www.state.ia.us/tax
                                                                                         Iowa Cigarette Tax Stamp Order Form
Permit Number                                                Mail to:                                                          For Office Use Only
                                                             Iowa Department of Revenue
                                                             Cigarette Stamp Order Processing
                                                             PO Box 10472
Purchaser’s Name                                             Des Moines, IA 50306-0472


                                                             Fed Ex mailing address:
Street Address                                               Iowa Department of Revenue
                                                             1305 E Walnut
                                                             Hoover Building - 3rd Floor
City, State, Zip Code                                        Des Moines, IA 50319

                                                             Questions:
                                                                                                                    Walk In
                                                             515/281-8807


Line Pack Carton            Stamp        Units             Stamp Type                Tax Value         Gross Cost             Less 2%             Net Cost
#        Size     Layout    Value        Ordered                                     Per Unit                                 Discount

1        20’s      2x5       36¢       _____________   Roll(s) of 30,000           @$10,800.00
                                                                  (old)

2                  2x5       36¢       _____________   Sheet(s) of 150             @$54.00

3                  1 x 10    36¢       _____________   Sheet(s) of 150             @$54.00
                                                            (Camel wides)

4        25’s      2x4       45¢       _____________   Roll(s) of 7,200            @$3,240.00
                                                           (Marlboro 25’s)

5                  1 x 10    45¢       _____________   Roll(s) of 7,200            @$3,240.00

6                  1 x 10    45¢       _____________   Sheet(s) of 150             @$67.50

     Total Remitance Due with Order (Add Net Cost lines 1 through 6). Make check payable to: Treasurer, State of Iowa.
     Payment is required with this completed form. No credit available.

     Permit holders may designate the following Receiving Agent (please indicate which one):                  Registered Mail
                                                                                                              Federal Express # _______________________


 _______________                         ______________                     ______________________________________________
           Telephone #                         Attention                                    Signature of Purchaser                            Date

                                           For Authorized Agent’s Use only - Stamp Serial Numbers
 Stamp Type                            Stamp Serial Numbers                            Stamp Type                      Stamp Serial Numbers
    (line #1-6)                                                                          (line #1-6)

                                from                         to                                                 from                        to

                                from                         to                                                 from                        to

                                from                         to                                                 from                        to

                                from                         to                                                 from                        to

        Check Date _________________ Check Number ______________
        The undersigned states that he/she is authorized to sell Cigarette Stamps as an agent of the Iowa Department of Revenue and certifies that the
        information contained is correct and that the total revenue collected is as stated.

                             Iowa Department of Revenue or _________________________________________________
                                                                                   Agent’s Organization

     _________________________                                 _________________________________________________
                   Agent’s Printed Name                                               Signature of Agent                                    Date

                                                           See reverse side for information on stamps                                            70-044a (5/17/04)

COPIES:                White - Dept. of Revenue                           Yellow - Agent/ Bank or Department              Pink - Taxpayer
       Iowa Department of Revenue
       www.state.ia.us/tax
                                                                                           Iowa Cigarette Tax Payment Indicators



                               IOWA CIGARETTE TAX PAYMENT INDICATORS
                    Tax                                  Cost of                  Carton
Line         Types of Indicators Unit                Minimum Quantity             Used On               Configuration             Application
 1           Rolls of Heat Applied     36¢           30,000 stamps per roll       Packs of 20’s               2x5                 Meyercord
             36¢ Stamps                              $10,800.00 gross                                                             Machine,
                                                     $10,584.00 net                                                               or Hand Iron

 2           Sheets of Heat Applied    36¢           150 stamps per sheet         Packs of 20’s               2x5                 Hand Iron
             36¢ Stamps                              $54.00 gross
                                                     $52.92 net

 3           Sheets of Heat Applied    36¢           150 stamps per sheet         Camel Wides 20’s            1 x 10              R J Reynolds
             36¢ Stamps                              $54.00 gross                                                                 Hand Iron
                                                     $52.92 net

 4           Rolls of Heat Applied     45¢           7,200 stamps per roll        Marlboro 25’s               2x4                 Meyercord
             45¢ Stamps (2 x 4)                      $3,240.00 gross              Marlboro Light 25’s                             Machine
                                                     $3,175.20 net

 5           Rolls of HeatApplied      45¢           7,200 stamps per roll        Century 25’s                1 x 10              R J Reynolds
             45¢ Stamps (1 x 10)                     $3,240.00 gross                                                              Hand Iron
                                                     $3,175.20 net

 6           Sheets of Heat Applied    45¢           150 stamps per sheet         Packs of 25’s               1 x 10              Hand Iron
             45¢ Stamps                              $67.50 gross                 Richland 25’s
                                                     $66.15 net

 Please note: Purchases may also be made in person on the 3rd floor of the Hoover State Office Building or at an authorized bank in your area.




                                                                                                                                   70-044b (06/20/03)

								
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