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MONTANA
                                                                                                                                                   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
Schedule M – Insignias Refund Recap
For the period of ___________________________________________

Business name ____________________________________________ Phone _________________________

                                                                        Invoices Information                                                                   Number of              Tax /
   Credit                                                                                                                                                                                           Total Tax
                                                                                                                                                                 packs                Pack
  Memo ID                                                                                                                                                                                          (A X B = C)
                                                                                                                                                                  (A)                  (B)
                             Business Name                               Address                          City         State      Zip          Phone
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125
                                                                                                                                                                                                   $
                                                                                                                                                                                  20/Pk - $1.70
                                                                                                                                                                                                   $
                                                                                                                                                                                  25/Pk - $2.125

                                                                                                                                                                                                   $
Total column C this page – Add total tax for this page only ....................................................................................................................................

                                                                                                                                                                                                   $
Total refund from all pages – Fill on last page only; total column C value on CT-203 line 1, section 1 ...............................................................

                                                                                                                                                                                                           343

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gov revenue formsandresources forms CT203

  • 1. MONTANA 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
  • 2. Schedule M – Insignias Refund Recap For the period of ___________________________________________ Business name ____________________________________________ Phone _________________________ Invoices Information Number of Tax / Credit Total Tax packs Pack Memo ID (A X B = C) (A) (B) Business Name Address City State Zip Phone $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ 20/Pk - $1.70 $ 25/Pk - $2.125 $ Total column C this page – Add total tax for this page only .................................................................................................................................... $ Total refund from all pages – Fill on last page only; total column C value on CT-203 line 1, section 1 ............................................................... 343