Form Cigarette Refund - Claim For Refund Of Nevada Cigarette Excise Tax Based On Destruction Of State-Taxed Cigarettes -
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1STATE OF NEVADA
DEPARTMENT OF TAXATION
1550 E. College Parkway, Suite 115
Carson City, NV 89706-7921
Web Site:
CLAIM FOR REFUND OF NEVADA CIGARETTE EXCISE TAX
BASED ON DESTRUCTION OF STATE-TAXED CIGARETTES
Wholesale Cigarette Dealer’s
Date:
License Number:
Manufacturers Date of Affidavit AFTER 1/22/04
Manufacturers Date of Affidavit PRIOR to 1/22/04
No. Per
No. of
Rate
Total
No. Per
No. of
Rate
Total
x
=
x
=
Pkg.
Packages
$
$
Pkg.
Packages
$
$
20
.80
20
.35
x
=
x
=
25
1.00
25
.4375
x
=
x
=
10
.40
10
.175
x
=
x
=
GROSS
GROSS
TOTALS
TOTALS
Less .0025 or 0.25% Discount
Less.03 or 3% Discount
Previously Allowed
Previously Allowed
$
$
NET TOTAL
NET TOTAL
RETAILERS/WHOLESALERS
CERTIFICATION
I/We certify that the above is a true and correct listing of the cigarettes that have been taken from a Nevada Retailer or Wholesaler
for the purpose of destruction because of staleness.
Tobacco Co, Corp, Manufacturer, etc.
NV Retailers or Wholesaler
Title
Title
Address
Address
City / State
City / State
Representative Signature
Representative Signature
INFORMATION ON NEVADA LAW REGARDING CLAIMS FOR REFUND
Nevada Revised Statute (NRS) 370.280 provides for refunds to cigarette dealers, manufacturers or their representatives, for the face value of
the cigarette revenue stamp tax paid, less any discount previously allowed upon cigarettes destroyed because the cigarettes had become
stale. Applications for refunds shall be submitted in an amount of not less than $15 and shall be accompanied by an affidavit of the
application setting forth: a)The number of packages of cigarettes destroyed for which refund is claimed; b) The date or dates on which the
cigarettes were destroyed and the place where destroyed; c) That the cigarettes were actually destroyed because they had become stale; d)
By whom the cigarettes were destroyed; and e) Other information which the Department may require.
INSTRUCTIONS FOR COMPLETING FORM
Provide the wholesale dealers license number and date where indicated. In the table provided, complete all blank fields applicable to the
refund being requested. If the manufacturers date of affidavit is AFTER 1/22/04 the left portion of the table is to be completed. If the
manufacturers date of affidavit is PRIOR to 1/22/04 the right portion of the table is to be completed. Enter the number of p ackages being
claimed on the row which corresponds to the number of cigarettes per package, multiply the number of packages entered by the dollar rate
listed for each line item and place the total dollar amount in the total column for each line item. Add each line item and p lace totals in the
gross totals row, listing totals for the total number of packages destroyed and the total dollar amount requested as refund for destroyed
cigarettes. Determine the discount by multiplying the gross total $ by .0025 or 0.25% and list this amount in the applicable row. Subtract
the discount from the gross total $ and list the amount in the net total column. Submit original claim for refund form to the Department of
Taxation along with original affidavit(s). Faxed copies will not be accepted as original signatures are required. This form can be found on
our website at
/
Distribution:
Original To Dept of Taxation
Form:
Cigarette Refund
Revised: 06/2009
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