Form 70-044 - Iowa Cigarette Tax Stamp Order Form
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1
2Iowa Department of Revenue
Iowa Cigarette Tax Stamp Order Form
For Office Use Only
Mail to:
Iowa Department of Revenue
Permit Number
Cigarette Stamp Order Processing
PO Box 10472
Des Moines, IA 50306-0472
Purchaser’s Name
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
E-mail Address
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
2 x 5
$1.36
___________
Roll(s) of 30,000
@$40,800.00
2
2 x 5
$1.36
___________
Sheet(s) of 150
@$204.00
3
1 x 10 $1.36
___________
Sheet(s) of 150
@$204.00
(Camel wides)
4
25’s
2 x 4
$1.70
___________
Roll(s) of 7,200
@$12,240.00
(Marlboro 25’s)
5
1 x 10 $1.70
___________
Roll(s) of 7,200
@$12,240.00
6
1 x 10 $1.70
___________
Sheet(s) of 150
@$255.00
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.
Stamps will be delivered in accordance with the Iowa Department of Revenue’s mailing
policy or permit holders may designate delivery at their own expense by Fed Ex Next Day
12:00 Service (please indicate which one):
IDR’s mailing service
Fed Ex Account #
_______________
______________
______________________________________________
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
(lines 1-6)
(lines 1-6)
from
to
from
to
from
to
from
to
from
to
from
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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 (06/11/10)
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