Form 70-039 Iowa Cigarette Refund Affidavit - Iowa

Form 70-039 is a Iowa Department of Revenue form also known as the "Iowa Cigarette Refund Affidavit". The latest edition of the form was released in May 5, 2017 and is available for digital filing.

Download a PDF version of the Form 70-039 down below or find it on Iowa Department of Revenue Forms website.

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Iowa Cigarette Refund Affidavit
Cigarettes Returned to Manufacturers
https://tax.iowa.gov
Permit Number
Federal Employer Identification Number
Permit Holder Name
Mailing Address
City
State
ZIP
The above permit holder hereby claims a refund of Iowa cigarette tax in accordance with Chapter 453A,
Iowa Code, for unsalable cigarettes and/or little cigars that were returned to the manufacturer after Iowa tax
stamps were affixed.
The following information is submitted in support of this claim and a manufacturer’s affidavit is attached.
A
B
C
D
E
F
G
H
I
J
Number
Number
Tax
Gross Tax
Total Gross
Manufacturer
Date
Invoice
Tax
Gross Tax
Packs
Packs
Rate
Paid
Tax Paid
Number
Rate
Paid (D x E)
20’s
25’s
(G x H)
(F + I)
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
Subtotal: $ ______________
Less 2% discount: $ ______________
Total refund claim: $ ______________
The undersigned states, under penalty of perjury, that all the information contained on this form is true and
accurate.
Signature
Title
Subscribed and sworn to before me this day of
Notary public
Submit this form to:
Mailing Address:
OR
For Office Use Only
Iowa Department of Revenue
Delivery Address:
Denied
Tax Management Division
Iowa Department of Revenue
Refund
Compliance Services
Hoover Bldg., Cigarette Tax
Approved
PO Box 10472
1305 E Walnut St.
Date
Des Moines IA 50306-0472
Des Moines IA 50319
Questions: Call 515-281-6134 or email IDRCigarette@iowa.gov.
70-039 (05/05/17)
Iowa Cigarette Refund Affidavit
Cigarettes Returned to Manufacturers
https://tax.iowa.gov
Permit Number
Federal Employer Identification Number
Permit Holder Name
Mailing Address
City
State
ZIP
The above permit holder hereby claims a refund of Iowa cigarette tax in accordance with Chapter 453A,
Iowa Code, for unsalable cigarettes and/or little cigars that were returned to the manufacturer after Iowa tax
stamps were affixed.
The following information is submitted in support of this claim and a manufacturer’s affidavit is attached.
A
B
C
D
E
F
G
H
I
J
Number
Number
Tax
Gross Tax
Total Gross
Manufacturer
Date
Invoice
Tax
Gross Tax
Packs
Packs
Rate
Paid
Tax Paid
Number
Rate
Paid (D x E)
20’s
25’s
(G x H)
(F + I)
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
$1.36
$1.70
$
Subtotal: $ ______________
Less 2% discount: $ ______________
Total refund claim: $ ______________
The undersigned states, under penalty of perjury, that all the information contained on this form is true and
accurate.
Signature
Title
Subscribed and sworn to before me this day of
Notary public
Submit this form to:
Mailing Address:
OR
For Office Use Only
Iowa Department of Revenue
Delivery Address:
Denied
Tax Management Division
Iowa Department of Revenue
Refund
Compliance Services
Hoover Bldg., Cigarette Tax
Approved
PO Box 10472
1305 E Walnut St.
Date
Des Moines IA 50306-0472
Des Moines IA 50319
Questions: Call 515-281-6134 or email IDRCigarette@iowa.gov.
70-039 (05/05/17)

Download Form 70-039 Iowa Cigarette Refund Affidavit - Iowa

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