Free CG-114 - New York

New York State Department of Taxation and Finance

Transaction and Transfer Tax Bureau -- FACCTS/Cigarette Tax

CG-114
(6/08)

See Form CG-114-I for instructions before completing this form, and for information on reimbursement of the New York City tax.

Claim for Redemption/Refund of Cigarette Tax Stamps and Prepaid Sales Tax
(Sections 476 and 1121 of the Tax Law)
Employer identification number (EIN) Agent's license number Social security number State ZIP code NYS sales tax identification number Check all that apply: agent

Legal name of claimant Street address City

chain store retailer

wholesaler

Part 1 -- Claim for redemption of unused or damaged cigarette tax stamps and prepaid sales tax - Stamping agents only
Date stamps were purchased (mm-dd-yyyy)

Column A
Cig tax stamp denomination
(see instructions)

Column B
Prepaid sales tax per pack
(see instructions)

Column C
Number of stamps

Column D
Cigarette tax paid
(A × C)

Column E
Commission rate

Column F
Commission amount
(D × E)

Column G
Cigarette tax paid less commission
(D ­ F)

Column H
Prepaid sales tax paid
(B × C)

2.75 state 2.75 state 2.75 joint 2.75 joint 3.4375 state 3.4375 joint

Totals 1 Total cigarette tax paid less commission (from Column G) .................................................................................. 2 Total prepaid sales tax paid (from Column H) ...................................................................................................... 3 Total redemption requested (add lines 1 and 2) ................................................................................................... Part 2 -- Claim for refund for stamps affixed to packages of cigarettes and prepaid sales tax
Date stamps were purchased (mm-dd-yyyy)

1. 2. 3.

Column A
Cig tax stamp denomination
(see instructions)

Column B
Prepaid sales tax per pack
(see instructions)

Column C
Number of stamps

Column D
Cigarette tax paid
(A × C)

Column E
Commission rate

Column F
Commission amount
(D × E)

Column G
Cigarette tax paid less commission, if applicable
(D ­ F)

Column H
Prepaid sales tax paid
(B × C)

(applicable to stamping agents only)

2.75 state 2.75 state 2.75 joint 2.75 joint 3.4375 state 3.4375 joint

Totals 4 Total cigarette tax paid less commission (from Column G) .................................................................................. 5 Total prepaid sales tax paid (from Column H) ...................................................................................................... 6 Total refund requested (add lines 4 and 5) ........................................................................................................... Part 3 -- Total redemption/refund requested (add lines 3 and 6) ...........................................................................

4. 5. 6. 7.

Caution: Read this claim before signing. Presenting a false or fraudulent claim constitutes a felony (Penal Law, section 175.35).
Certification: I hereby certify that the foregoing statement is true and correct in every particular; that the cigarette tax stamps described above were purchased by the claimant herein for the purpose of affixing them to cigarette packages as required by law; that they are no longer required by the claimant for such purpose, or they are so damaged as to be unfit for use; that no claim has been heretofore presented for the redemption of any of the above described stamps; that no credit for the prepaid sales tax has been heretofore claimed on a sales tax return, and that the refund of the net purchase price of such stamps, including the prepaid sales tax, claimed herein is just and lawfully due from New York State.
Date Date Authorized signature Preparer's signature Print name Preparer's address Official title

Attach additional sheets as necessary.

CG-114 (6/08) (back)
For department use only

I certify that I have examined the packages of cigarettes to which the stamps described on this form were attached and have removed or destroyed the stamps in the following quantities and denominations:

(Signature and full title)

(Date)

For auditor's use only

Amount allowed: $ Approved for payment:
(Tax technician)

Audited by
(Examiner) (Date) (Date)

Audited by
(Comptroller)

For office use only

Mail your claim form and any related attachments to:

NYS TAX DEPARTMENT TTTB FACCTS - CIGARETTE TAX UNIT W A HARRIMAN CAMPUS ALBANY NY 12227