"Application for a Tobacco Tax Rebate Under the Revenue Administration Act" - Newfoundland and Labrador, Canada

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Government of Newfoundland and Labrador
Department of Finance
Tax Administration Division
APPLICATION FOR A TOBACCO TAX REBATE UNDER THE
REVENUE ADMINISTRATION ACT
(LABRADOR WEST AND SOUTHERN LABRADOR)
THIS FORM MUST BE FORWARDED, WITH CERTIFIED COPIES OF PURCHASE INVOICES TO:
TAX ADMINISTRATION DIVISION, DEPARTMENT OF FINANCE, P.O. BOX 8720, ST. JOHN’S, NL A1B 4K1
Name
Address
Telephone Number:
Purchase Period From:
To:
Seller’s Number:
INFORMATION ON PURCHASES FOR THE PERIOD
DATE
INVOICE #
SUPPLIER’S NAME
NUMBER OF
FOR OFFICE
GRAMS OF
FOR OFFICE
CARTONS OF
USE ONLY
TOBACCO
USE ONLY
CIGARETTES
TOTAL PURCHASES FOR REBATE
TAX REBATE PER CARTON/GRAM (SEE BELOW)
REBATE AMOUNT (TOTAL MULTIPLIED BY THE TAX REBATE PER
CARTON/GRAM)
TOTAL REBATE CLAIMED
Rebate on cigarettes per carton of 20’s and 25’s
Rebate per gram of tobacco other than cigarettes and cigars
Effective June 1, 2021 - $37.50
Effective June 1, 2021 - $0.3936
CERTIFICATION
I hereby certify that, to the best of my knowledge and belief, the information provided on this form is true and correct, and that I understand it is a
serious offence to make a false statement in this claim.
Name of Authorized Signing Officer (please print)___________________________________________________________
Signature of Authorized Signing Officer___________________________________________________________________
Title ____________________________________________
Date _______________________________________
Telephone Number ____________________________
Email Address _______________________________________
Privacy and Confidentiality Notice
This information is collected for the purpose of the Department of Finance to process applications under the Revenue
Administration Act. All information you provide, both personal and business related, will be kept confidential and compliant
with the Access to Information and Protection of Privacy Act, 2015 (www.assembly.nl.ca/legislation/sr/statutes/a01-2.htm). If
you have any questions regarding privacy and confidentiality please contact the Tax Administration Division toll free at
1-877-729-6376.
FOR OFFICE USE ONLY
REVIEWED BY:
DATE:
APPROVED BY:
DATE:
P.O. Box 8720, St. John’s, NL, Canada A1B 4K1 Telephone (877) 729-6376 Fax (709) 729-2856 Email taxadmin@gov.nl.ca
www.fin.gov.nl.ca/fin/tax_programs_incentives/business/taxation.html
Government of Newfoundland and Labrador
Department of Finance
Tax Administration Division
APPLICATION FOR A TOBACCO TAX REBATE UNDER THE
REVENUE ADMINISTRATION ACT
(LABRADOR WEST AND SOUTHERN LABRADOR)
THIS FORM MUST BE FORWARDED, WITH CERTIFIED COPIES OF PURCHASE INVOICES TO:
TAX ADMINISTRATION DIVISION, DEPARTMENT OF FINANCE, P.O. BOX 8720, ST. JOHN’S, NL A1B 4K1
Name
Address
Telephone Number:
Purchase Period From:
To:
Seller’s Number:
INFORMATION ON PURCHASES FOR THE PERIOD
DATE
INVOICE #
SUPPLIER’S NAME
NUMBER OF
FOR OFFICE
GRAMS OF
FOR OFFICE
CARTONS OF
USE ONLY
TOBACCO
USE ONLY
CIGARETTES
TOTAL PURCHASES FOR REBATE
TAX REBATE PER CARTON/GRAM (SEE BELOW)
REBATE AMOUNT (TOTAL MULTIPLIED BY THE TAX REBATE PER
CARTON/GRAM)
TOTAL REBATE CLAIMED
Rebate on cigarettes per carton of 20’s and 25’s
Rebate per gram of tobacco other than cigarettes and cigars
Effective June 1, 2021 - $37.50
Effective June 1, 2021 - $0.3936
CERTIFICATION
I hereby certify that, to the best of my knowledge and belief, the information provided on this form is true and correct, and that I understand it is a
serious offence to make a false statement in this claim.
Name of Authorized Signing Officer (please print)___________________________________________________________
Signature of Authorized Signing Officer___________________________________________________________________
Title ____________________________________________
Date _______________________________________
Telephone Number ____________________________
Email Address _______________________________________
Privacy and Confidentiality Notice
This information is collected for the purpose of the Department of Finance to process applications under the Revenue
Administration Act. All information you provide, both personal and business related, will be kept confidential and compliant
with the Access to Information and Protection of Privacy Act, 2015 (www.assembly.nl.ca/legislation/sr/statutes/a01-2.htm). If
you have any questions regarding privacy and confidentiality please contact the Tax Administration Division toll free at
1-877-729-6376.
FOR OFFICE USE ONLY
REVIEWED BY:
DATE:
APPROVED BY:
DATE:
P.O. Box 8720, St. John’s, NL, Canada A1B 4K1 Telephone (877) 729-6376 Fax (709) 729-2856 Email taxadmin@gov.nl.ca
www.fin.gov.nl.ca/fin/tax_programs_incentives/business/taxation.html