Form TC-564 "Tobacco/Cigarette Tax Refund Request" - Utah

What Is Form TC-564?

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

Form Details:

  • Released on May 1, 2020;
  • The latest edition provided by the Utah State Tax Commission;
  • 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 fillable version of Form TC-564 by clicking the link below or browse more documents and templates provided by the Utah State Tax Commission.

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Download Form TC-564 "Tobacco/Cigarette Tax Refund Request" - Utah

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Utah State Tax Commission
210 N 1950 W • Salt Lake City, UT 84134 • tax.utah.gov
TC-564
Tobacco/Cigarette Tax
Rev. 5/20
Refund Request
Name of business entity
Street address (physical location)
City
State
ZIP Code
Mailing address
City
State
ZIP Code
Contact person last name
Contact’s first name
Middle initial
Contact’s phone number
Contact’s email
FEIN
Utah tobacco account number
A. Cigarette Stamp Refund Request
Reason for request (mark one):
 Stamps were destroyed (attach affidavit)
 Stamp return — stamps became obsolete (must return stamps) . . . . . . . . . . Roll number(s): ______________
 Stamp return — entity stopped doing business (must return stamps) . . . . . . Roll number(s): ______________
 Nontaxable sales to members of the Ute Tribe (attach exemption documentation)
Stamp refund calculation:
Stamp Type
Quantity
Stamp Value
Gross Refund
Discount
Net Refund
(Gross Refund minus Discount)
1. PM 20 pack
x $1.70 = $
x .04 =
$
$
2. PM 25 pack
x $2.125 = $
x .04 =
$
$
3. NPM 20 pk
x $2.05 = $
x .04 =
$
$
A Total stamp refund request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
$
B. Cash Bond Refund Request
Reason for request (mark one):
 I am no longer a tobacco distributor
 I am no longer a stamper
 I no longer sell prefilled e-cigarettes or e-cigarette substances
 I am submitting a surety bond to replace a cash bond
 The above entity stopped doing business, effective (date): __ __ ___ __ __ __ ___
B Total bond refund requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
$
C. Total refund requested (add lines A and B)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
$
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form
Under penalty of falsification, I declare that, to the best of my knowledge, all the information in this Request and any
attached documentation is true and complete.
__ _ _ _ _ _ ____________________ __
___ _______________
______________
________________
Authorized Signature
Title
Date
Telephone
Clear form
Print Form
Utah State Tax Commission
210 N 1950 W • Salt Lake City, UT 84134 • tax.utah.gov
TC-564
Tobacco/Cigarette Tax
Rev. 5/20
Refund Request
Name of business entity
Street address (physical location)
City
State
ZIP Code
Mailing address
City
State
ZIP Code
Contact person last name
Contact’s first name
Middle initial
Contact’s phone number
Contact’s email
FEIN
Utah tobacco account number
A. Cigarette Stamp Refund Request
Reason for request (mark one):
 Stamps were destroyed (attach affidavit)
 Stamp return — stamps became obsolete (must return stamps) . . . . . . . . . . Roll number(s): ______________
 Stamp return — entity stopped doing business (must return stamps) . . . . . . Roll number(s): ______________
 Nontaxable sales to members of the Ute Tribe (attach exemption documentation)
Stamp refund calculation:
Stamp Type
Quantity
Stamp Value
Gross Refund
Discount
Net Refund
(Gross Refund minus Discount)
1. PM 20 pack
x $1.70 = $
x .04 =
$
$
2. PM 25 pack
x $2.125 = $
x .04 =
$
$
3. NPM 20 pk
x $2.05 = $
x .04 =
$
$
A Total stamp refund request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A
$
B. Cash Bond Refund Request
Reason for request (mark one):
 I am no longer a tobacco distributor
 I am no longer a stamper
 I no longer sell prefilled e-cigarettes or e-cigarette substances
 I am submitting a surety bond to replace a cash bond
 The above entity stopped doing business, effective (date): __ __ ___ __ __ __ ___
B Total bond refund requested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B
$
C. Total refund requested (add lines A and B)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C
$
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form
Under penalty of falsification, I declare that, to the best of my knowledge, all the information in this Request and any
attached documentation is true and complete.
__ _ _ _ _ _ ____________________ __
___ _______________
______________
________________
Authorized Signature
Title
Date
Telephone
TC-564_i.ai
TC-564 Instructions
Stamp Refund Calculation
General Information
Instructions
For information or help with this form, call 801-297-2200, or toll
free 1-800-662-4335.
Quantity
Enter the number of stamps destroyed, returned or
exempt.
Mailing
Gross Refund
Mail this form to:
Multiply the quantity by the stamp value and enter the
Utah State Tax Commission
result.
Miscellaneous Tax Section
210 N 1950 W
Discount
Salt Lake City, UT 84134-3500
Multiply the gross refund by .04 and enter the result.
Get forms online: tax.utah.gov
(This is the discount you received when you purchased
your stamps.)
Net Stamp Refund
____________________ _
Subtract the Discount from the Gross Refund and enter
the result.
If you need an accommodation under the Americans with
Total stamp refund request
Disabilities Act,
email taxada@utah.gov, or call 801-297-3811
Add the Net Stamp Refund from all stamp types and
or TDD 801-297-2020.
Please allow three working days for a
enter the total.
response.
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