INDIANA CIGARETTE TAX STAMP ORDER For Office Use Only ATTN: CIG TAX ATTN: CIG TAX Inv. Number: Process Date: Invoice Date: Post Office Box 901 5150 Decatur Blvd. CIG# Exp. Date: Indianapolis, Indiana 46206-0901 Indianapolis, Indiana 46241 CT-4A Mail to: Overnight or Certified Mail: State Form 46862 Indiana Department of Revenue Indiana Department of Revenue (R4/3-09) CIG LICENSE # If you have questions about this form please call 317-615-2710. You may also email orders to: INCigTax@dor.in.gov DATE: Quantity 1 2 3 # of Stamps 0 enter # of rolls Description Processed by: Rolls of 30M 99.5¢ Stamps, 20 Cigarettes Serial Nos. Price Amount $0.00 A $29,850.00 per roll 30,000 stamps per roll 0 enter # of sheets Sheets of 150 99.5¢ Stamps, 20 Cigarettes (WIDES) Serial Nos. $149.25 per sheet $0.00 B $0.995 per stamp $0.00 C $8,955.00 per roll $0.00 D $8,955.00 per roll $0.00 E 150 stamps per sheet 0 enter # of stamps Fuson Stamps, 99.5¢ per stamp, 20 Cigarettes Serial Nos. Number must be divisible by 300 7200T $1.24375 Stamps, 25 Cigarettes 4 0 enter # of rolls Serial Nos. 7200 stamps per roll/10 stamps per row 7200M $1.24375 Stamps, 25 Cigarettes 5 0 enter # of rolls Serial Nos. 7200 stamps per roll/12 stamps per row 0 Total Number of Stamps Ordered: Cigarette Papers: $12.00 per 100 sheet (no discount) Serial Nos. 6 enter # of sheets x $12.00 Indicate Payment Method Name of Company $0.00 F $0.00 G $0.00 H Gross Tax Total: Discount: $0.012 x total number of stamps: Net Tax Total: Bad Debt Credit (Please attach necessary forms): Total Cigarette Papers Total I $0.00 J $0.00 K Shipping (UPS Ground): L if you are using your account to ship, leave blank Payment enclosed: Authorized 30 Day Credit: Total Amount: $0.00 Shipping Address City State Zip Authorized Email Address 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. i.e. UPS Next Day Air, or FedEx Priority Overnight FedEx: Acct # Name, Title, and Phone Number (direct or include ext #) of Authorized Purchaser Service Acct # Service UPS: American LegalNet, Inc. www.FormsWorkFlow.com M