Form 0405-623 - Application To Purchase Cigarette Tax Stamps On Deferred Payments Basis
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1State of Alaska
Department use only
Envelope #
623
Application to Purchase Cigarette
FSN
SEQ #
Tax Stamps on Deferred Payments
Basis
Federal ID
EIN
SSN
License Number
License Period
Alaska Business License Number
Name
Telephone Number
Fax Number
Mailing Address
Contact Person
Contact Telephone Number
City
State
Zip + 4
Email Address
As provided in Alaska Statute 43.50.550(b), the undersigned, duly licensed by the State of Alaska Under AS 43.50.010 or AS 43.50.035,
herby applies to purchase cigarette tax stamps on a deferred payment basis in an amount not to exceed $ _____________________
in any one calendar month.
This application is accompanied by a surety bond executed by a corporation incorporated under the laws of the State of _______________
and authorized to engage in business as surety company in Alaska.
Attach completed form 04-041D (rev 10/03), Cigarette Tax Surety Bond.
Name of Surety Company
Bond Number
City
State
Zip + 4
Amount of Bond
Note: Amount of bond must equal 200 percent of the maximum dollar amount of allowed monthly cigarette stamp purchase.
Signature of Taxpayer or Representative
Date
Printed Name and Title of Taxpayer or Representative
Title
FOR DEPARTMENT USE ONLY
Application to purchase cigarette tax stamps on a deferred payment basis approved in the amount of $______________________
Application to purchase cigarette tax stamps on a deferred payment basis denied.
Signature
Title
Date
If approved, the above-named licensee may purchase cigarette tax stamps on a deferred payment basis until this date ______________
Pay online at
Mail to: Alaska Department of Revenue - Tax Division
or make check payable to State of Alaska
550 W 7th Ave Ste 500 Anchorage • AK 99501-3566
Telephone 907-269-6620
FAX 907-269-6644
623
Form 0405-623 rev 04/08 • page 1
Retain a copy for your records
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Parent category: Financial