Form 72-001-15 "Affidavit for Refund or Credit for Tobacco Stamps" - Mississippi

What Is Form 72-001-15?

This is a legal form that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Mississippi Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 72-001-15 by clicking the link below or browse more documents and templates provided by the Mississippi Department of Revenue.

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Download Form 72-001-15 "Affidavit for Refund or Credit for Tobacco Stamps" - Mississippi

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AFFIDAVIT FOR REFUND OR CREDIT
FOR TOBACCO STAMPS
Form 72-001-15
STATE OF ___________________________, COUNTY OF ___________________________ BEFORE ME,
the undersigned authority, on this day personally appeared _________________________________, who after
(NAME)
being by me first duly sworn, on oath deposed and said:
Under the penalty of perjury,
I hereby certify that I am the applicant (or, officer, agent or representative of the applicant), for a refund of the
value of tobacco stamps heretofore affixed to taxable cigarettes intended for sale in the State of Mississippi,
which cigarettes had become unfit for use and consumption, unsalable, or otherwise a legitimate loss because of
the fact that ________________________________________________________________________________
(recite the facts with reference to nature of damage, or other facts relied upon for refund; add attachment if
needed) which facts are personally known to the affiant to be true and correct, for the purpose of obtaining the
refund applied for. I understand and agree that any refund I receive will be in the form of new stamps of equal to
the aggregate value of the tax paid on the goods adjudged to be unfit for use, consumption, unsalable or otherwise
a legitimate loss. To the extent reasonably possible, I am including all damaged stamps or those stamps previously
affixed to otherwise unsalable cigarettes with this Affidavit.
WITNESS MY SIGNATURE, this _____ day of _________________, 20_____.
_____________________________________
_____________________________________
(PRINTED NAME)
(SIGNATURE)
___________________________________________
(OFFICIAL TITLE OF OFFICER)
_______________________________________________________________________________
(STREET ADDRESS)
_______________________________________________________________________________
(MAILING ADDRESS)
Telephone Numbers: Work (______) ___________________
Home (______) ___________________
Sales and Use Tax Bureau
P.O. Box 1033
Jackson, MS 39215
www.dor.ms.gov
Phone: 601.923.7015
FAX: 601.923.7034
AFFIDAVIT FOR REFUND OR CREDIT
FOR TOBACCO STAMPS
Form 72-001-15
STATE OF ___________________________, COUNTY OF ___________________________ BEFORE ME,
the undersigned authority, on this day personally appeared _________________________________, who after
(NAME)
being by me first duly sworn, on oath deposed and said:
Under the penalty of perjury,
I hereby certify that I am the applicant (or, officer, agent or representative of the applicant), for a refund of the
value of tobacco stamps heretofore affixed to taxable cigarettes intended for sale in the State of Mississippi,
which cigarettes had become unfit for use and consumption, unsalable, or otherwise a legitimate loss because of
the fact that ________________________________________________________________________________
(recite the facts with reference to nature of damage, or other facts relied upon for refund; add attachment if
needed) which facts are personally known to the affiant to be true and correct, for the purpose of obtaining the
refund applied for. I understand and agree that any refund I receive will be in the form of new stamps of equal to
the aggregate value of the tax paid on the goods adjudged to be unfit for use, consumption, unsalable or otherwise
a legitimate loss. To the extent reasonably possible, I am including all damaged stamps or those stamps previously
affixed to otherwise unsalable cigarettes with this Affidavit.
WITNESS MY SIGNATURE, this _____ day of _________________, 20_____.
_____________________________________
_____________________________________
(PRINTED NAME)
(SIGNATURE)
___________________________________________
(OFFICIAL TITLE OF OFFICER)
_______________________________________________________________________________
(STREET ADDRESS)
_______________________________________________________________________________
(MAILING ADDRESS)
Telephone Numbers: Work (______) ___________________
Home (______) ___________________
Sales and Use Tax Bureau
P.O. Box 1033
Jackson, MS 39215
www.dor.ms.gov
Phone: 601.923.7015
FAX: 601.923.7034