Form Cig-Refund Fillable Cigarette Refund Form
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Address) (City / State) (Date:) (No of Packages 10) (No of Packages 20) (No of Packages 25) (NV Retailers or Wholesaler) (Title) (Tobacco Co Corp Manufacturer etc ) (Total $ =) (Total $ =) (Total $ =) (Wholesale Cigarette Dealer s License Number:) 1550 E College Parkway Suite 115 Address application setting forth: a)The number of packages of cigarettes destroyed for which refund is claimed; b) The date or dates on which the BASED ON DESTRUCTION OF STATE TAXED CIGARETTES By whom the cigarettes were destroyed; and e) Other information which the Department may require Carson City NV 89706 7921 cigarettes Determine the discount by multiplying the gross total $ by 0025 or 0 25% and list this amount in the applicable row Subtract cigarettes were destroyed and the place where destroyed; c) That the cigarettes were actually destroyed because they had become stale; d) City / State CLAIM FOR REFUND OF NEVADA CIGARETTE EXCISE TAX claimed on the row which corresponds to the number of cigarettes per package multiply the number of packages entered by the dollar rate Date: DEPARTMENT OF TAXATION Distribution: Original To Dept of Taxation Form: Cigarette Refund Revised: 06/2009 for the purpose of destruction because of staleness GROSS gross totals row listing totals for the total number of packages destroyed and the total dollar amount requested as refund for destroyed 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 INFORMATION ON NEVADA LAW REGARDING CLAIMS FOR REFUND INSTRUCTIONS FOR COMPLETING FORM Less 0025 or 0 25% Discount Less 03 or 3% Discount License Number: 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 Manufacturers Date of Affidavit AFTER 1/22/04 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 Manufacturers Date of Affidavit PRIOR to 1/22/04 NET TOTAL Nevada Revised Statute (NRS) 370 280 provides for refunds to cigarette dealers manufacturers or their representatives for the face value of No of No Per NV Retailers or Wholesaler our website at http://tax nv gov/ Package Previously Allowed 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 Representative Signature RETAILERS/WHOLESALERS CERTIFICATION stale Applications for refunds shall be submitted in an amount of not less than $15 and shall be accompanied by an affidavit of the STATE OF NEVADA Taxation along with original affidavit(s) Faxed copies will not be accepted as original signatures are required This form can be found on the cigarette revenue stamp tax paid less any discount previously allowed upon cigarettes destroyed because the cigarettes had become 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 Title Tobacco Co Corp Manufacturer etc Total TOTALS Web Site: http://tax nv gov Wholesale Cigarette Dealer s