Cigarette Tax Stamp Order Form
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620
Alaska
Cigarette Tax Stamp Order Form
License Number
Period (yyyy/mm)
AK Business License Number
Federal ID
EIN
SSN
Business Name
Phone Number
Fax Number
Mailing Address
Contact Person
Contact Phone Number
City
State
ZIP + 4
Contact Email
Payment is due at the time of order unless you are approved for deferred payment. Payment must be in the form of a certified check,
cashier’s check or U.S. Postal Money Order made payable to “State of Alaska”; by wire transfer, or by using the Online Tax Information
System (OTIS), the Department of Revenue’s Online Payment service. In special circumstances, the department will accept a
company check (see instructions).
Electronic Payment Information
Note: If your liability exceeds $100,000 you must pay using the Online Tax Information System (OTIS) at or by wire transfer.
Check if you are paying by:
OTIS (confirmation # ___________________________)
Wire transfer (date ______________)
Check here if you are paying under a deferred payment plan. See instructions for information. If payment is authorized under a
deferred payment plan, payment is due by the end of the month following the month the stamps were ordered.
Filling of Stamp Orders. For those paying under a deferred payment plan, stamp orders will be filled within the same business day
provided the order is received before 10 a.m. Alaska Standard Time (AST). For all others, stamp orders will be filled once verification of
funds has been received by the Tax Division (see instructions).
Stamp Order and Calculation of Cigarette Tax Due
See page 1 of the instructions for definitions of PM and NPM cigarettes.
PM cigarettes
NPM cigarettes
PM cigarettes
20 cigarettes/pack
20 cigarettes/pack
25 cigarettes/pack
Machine stamp rolls
Hand-applied stamps
Hand-applied stamps
Hand-applied stamps
(15,000 per roll)
(lots of 150 stamps)
(sheets of 150 stamps)
(sheets of 150 Stamps)
15,000
150
150
150
1 Type and quantity of stamps
1
2 Number of rolls, lots or sheets
2
3 Total stamps. Multiply line 1 by line 2
3
$ 2.00
$ 2.00
$ 2.25
$ 2.50
4 Value of each stamp
4
$
$
$
$
5 Tax. Multiply line 3 by line 4
5
6
$
6 Cigarette tax due. Add the total of all columns in line 5
7
$
7 Cigarette tax paid with order
Signature of Licensee, Agent or Designee
Date
Type or print name
Title
Mail to: ALASKA DEPARTMENT OF REVENUE
Pay online at
TAX DIVISION
or make check payable to State of Alaska
550 W 7TH AVE STE 500
ANCHORAGE AK 99501-3566
Phone 907-269-6620 • Fax 907-269-6644
Stamp order
Date filled
Funds
Filled by
Checked by
Funds verified by
Date
Batch #
Receipt #
Order #
620
0405-620 rev 11/10
Retain a copy for your records
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