Montana Form Ct-203 - Insignias Refund Application
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1
2MONTANA
CT-203
Rev 1-05
Insignias Refund Application
Business Name
License No.
Date
Principal or Agent Name
Phone
Address
Fax
City
State
Zip
Instruction for form preparation
1. Prepare in duplicate. Submit the original to Montana Department of Revenue, Customer Intake Process, P.O. Box
1712, Helena, MT 59604-1712. Retain a duplicate in company file for field audit purposes.
2. Attach with this refund request all copies of the credit memo, or other documents sent to the wholesaler indicating that
credit or refund of the Montana cigarette tax has been issued.
Section 1 – Refund recap
1. Total value of stamps (total from all schedule M) .................................................... _____________________
2. Discount rate ............................................................................................................
0.0045
3. Total discount (multiply line 1 by line 2) ................................................................... _____________________
4. Net Refund (subtract line 3 from line 1) ................................................................... _____________________
Section 2 – Notary signature
State of ____________________________________________
ss.
County of __________________________________________
___________________________________________________ , being first duly sworn on oath deposes and
says: That he / she is the ______________________________ of the above named applicant, and has
(Title)
personal knowledge of the matter set forth; that the cigarettes are not salable, and the cigarette tax pack units
listed within the attached schedule and which are submitted for refund are all State of Montana cigarette tax
insignia which are affixed to the unsalable cigarettes; that credit or refund for the net cost of the tax insignia has
been given to a Montana cigarette wholesaler and that the cigarettes will not be sold at any time.
___________________________________________________
Signature of Affiant
Subscribed and sworn to before me this ______________ day of ___________ , 20 ______
_________________________________ , Commission expires: ______________________________________
Notary Public Signature
Date
343
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