Cigarette Tax Stamp Order {CT-4A}

State Form 46862 (R9 / 7-16) CT-4A Indiana Cigarette Tax Stamp Order If you have questions about this form please call (317) 615-2710. Orders may be mailed to the address at the bottom of this form, emailed to INCigTax@dor.in.gov or faxed to (317) 615-2691. For Office Use Only Inv. Number: Invoice Date: CIG# Exp. Date: TID # _________________________________ LOC # ________ Date: _________________ Description Rolls of 30M 99.5¢ Stamps, 20 Cigarettes Processed By _________________ Price Amount 1. Enter number of rolls (30,000 stamps per roll) ................................................................................ _______ X $29,850 per roll ______________ Enter number of stamps .......................................................................................... Description Serial Numbers Processed By Sheets of 150 99.5¢ Stamps, 20 Cigarettes (WIDES) _______________________________________ _________________ Price Amount 2. Enter number of sheets (150 stamps per sheet) ............................................................................. _______ X $149.25 per sheet _____________ Enter number of stamps .......................................................................................... Description Serial Numbers Processed by Fuson Stamps, 99.5¢ per stamp, 20 Cigarettes _______________________________________ _________________ Price Amount 3. Enter number of stamps (number must be divisible by 300) ........................................................... _______ X $0.995 per stamp ______________ Enter number of stamps .......................................................................................... Description Serial Numbers 7200T, $1.24375 Stamps, 25 Cigarettes _______________________________________ Processed by _________________ Price Amount 4. Enter number of rolls (7200 stamps per roll/10 stamps per row) .................................................... _______ X $8,955 per roll ______________ Enter number of stamps .......................................................................................... Description Serial Numbers Processed by 7200M, $1.24375 Stamps, 25 Cigarettes _______________________________________ _______________ Price Amount 5. Enter number of rolls (7200 stamps per roll/12 stamps per row) .................................................... _______ X $8,955 per roll ______________ Enter number of stamps .......................................................................................... 6. 7. 8. 9. Total number of stamps ordered Add tax from lines 1 through 5 .......................................................................................................................... Gross Tax Total Multiply $0.013 X total number of stamps from line 6 ...................................................................................................Discount Subtract line 8 from line 7....................................................................................................................................... Net Tax Total ______________ ______________ ______________ ______________ Serial Numbers _____________________________________ 10. Bad Debt Credit (Please attach necessary forms) ......................................................................................................................... 11. Subtract line 10 from line 9...................................................................................................................................................Total ______________ Description Serial Numbers Processed by Cigarette Papers: $12 per 100 sheet (no discount) _______________________________________ _______________ Price 12. Enter number of sheets ..................................................................................................................... _______ X $12 per sheet 13. Shipping (UPS Ground) - Leave blank if you are using your account to ship. ............................................................................. 14. Add lines 11, 12 and 13 ......................................................................................................................................... Total Amount _________________________________________________________ Name of Company _________________________________________________________ Shipping Address _______________________________ ____________ ___________ City State Zip Code _________________________________________________________ Name, Title and Telephone Number (direct or include ext number) of Authorized Purchaser Mail to: Indiana Department of Revenue Attention: Cigarette Tax P.O. Box 901 Indianapolis, IN 46206-0901 Overnight or Certified Mail: Indiana Department of Revenue Attention: Cigarette Tax 7811 Milhouse Road, Suite P Indianapolis, IN 46241-9612 American LegalNet, Inc. www.FormsWorkFlow.com Amount ______________ ______________ ______________ Indicate Payment Method: Payment Enclosed Authorized 30 Day Credit Shipping Options: If you wish to use your company's shipping account please enter the account number below and specify service you wish to use (e.g. UPS Next Day Air, or FedEx Priority Overnight). ________________________________ _________________________ FedEx Account Number Service ________________________________ _________________________ UPS Account Number Service