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Alaska Transfer of Cigarette Tax Stamps Form

In the State of Alaska, cigarette excise tax (pursuant to AS 43.50) must be paid using cigarette tax stamps. When filing for the income tax return, cigarette tax stamps are attached to the form. This form is for the use of individuals/parties that seek to transfer ownership of tax stamps to another individual/party.Download

Extracted Text for Proper Search

Part I - Information About The Licensee Transferring The Cigarette Tax Stamps
EIN	License Number(s)	Period Ending (Year/Month)	AK Business License Number	
SSN
Name 	Phone Number	Fax Number	
Mailing Address 	Contact Person	Contact Telephone Number	
City 	State	ZIP + 4 	Contact Email	
Part II - Information About The Licensee Receiving The Cigarette Tax Stamps
EIN	License Number(s)	Period Ending (Year/Month)	AK Business License Number	
SSN
Name 	Phone Number	Fax Number	
Mailing Address 	Contact Person	Contact Telephone Number	
City 	State	ZIP + 4 	Contact Email	
Part III - Transfer Of Cigarette Tax Stamps - See Instructions	
Number Of 
Cigarettes Per 	
Stamp
(a)	
Serial Number(S) On Stamps 	
(b)	
Number Of Stamps 	
Transferred 	
(c)	
Value Of Tax 	
Stamps
(d)	
Total Value Of Tax Stamps 	
Transferred (C) X (D) 	
(e)	
20 (PM)	$2.00	
25 (PM)	$2.50	
  20 (NPM)	$2.25	
Reason For The Transfer
Signature Of Licensee Transferring The Cigarette Tax Stamps 	Signature Of Licensee Receiving The Cigarette Tax Stamps	
Printed Name	Printed Name	
Title 	Date	Title 	Date	
Department Use Only
Signature 	Title	Date	
Transfer of cigarette tax stamps approved	Transfer of cigarette stamps not approved	
Mail to:  Alaska Department Of Revenue, 550 W 7th Ave STE 500, Anchorage AK 99501-3555
Alaska
Transfer of Cigarette Tax Stamps	
622	
622	
0405-622  Rev 08/12
Next: Alaska Alcoholic Beverage Excise Tax Return Form Previous: Arizona S Corporation Income Tax Return Form
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