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application for refund of tobacco tax pursuant to the revenue ...

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GOVERNMENT OF NEWFOUNDLAND AND LABRADORDEPARTMENT OF FINANCETAX ADMINISTRATION DIVISIONAPPLICATION FOR REFUND OF TOBACCO TAXPURSUANT TO THE REVENUE ADMINISTRATION ACTName:Address:Postal Code:Remitter Number: For <strong>the</strong> period <strong>of</strong>: <strong>to</strong>Refund Requested: $ . Telephone Number: ( ) Fax: ( )Reason <strong>for</strong> Refund <strong>of</strong> Tobacco Tax S<strong>to</strong>len Tobacco Products O<strong>the</strong>r(Please provide details and complete <strong>the</strong> <strong>for</strong>m on <strong>the</strong> following page)For s<strong>to</strong>len <strong><strong>to</strong>bacco</strong> products please include <strong>the</strong> following documentation: <strong>the</strong> police report number and <strong>the</strong> Officer in charge or (responded) a copy <strong>of</strong> <strong>the</strong> invoices <strong>for</strong> <strong>the</strong> s<strong>to</strong>len items a copy <strong>of</strong> <strong>the</strong> insurance claim (if no insurance claim filed, please explain why)I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT TO THE BEST OF MYKNOWLEDGE AND BELIEF OF THE UNDERSIGNED AND THAT ALL RELEVANT FACTS HAVE BEEN REVEALEDNAME (Please Print)TITLESIGNATUREDATEIt is a serious <strong>of</strong>fence <strong>to</strong> make a false statement or <strong>to</strong> provide false in<strong>for</strong>mation on this <strong>refund</strong> claim. The Ministerreserves <strong>the</strong> right <strong>to</strong> audit records <strong>to</strong> substantiate this claim.THIS FORM AND RELATED INFORMATION MUST BE FORWARDED TO:Dept. <strong>of</strong> Finance, Tax Administration Division, P.O. Box 8720, Confederation Bldg., St. John’s, NL, A1B 4K1Telephone: 1-877-729-1695 Fax: (709) 729-2856 E-mail: <strong>tax</strong>admin@mail.gov.nl.ca


Please complete <strong>the</strong> following table giving <strong>the</strong> description <strong>of</strong> <strong>the</strong> product and <strong>the</strong> quantity purchased.• For fine cut <strong><strong>to</strong>bacco</strong> <strong>the</strong> size <strong>of</strong> <strong>the</strong> packaging. • For cigars a detail description and <strong>the</strong> amount <strong>of</strong> <strong>tax</strong> paid.Detailed Listing <strong>of</strong> Items S<strong>to</strong>len Tax Rates Effective March 30, 2010Description Units Quantities Tax Rate TaxCigarettes/ Preportioned Tobacco Sticks Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Car<strong>to</strong>ns $38.00Sub-<strong>to</strong>tal Dollar Amount <strong>of</strong> CigarettesAll O<strong>the</strong>r Tobacco Products Grams 0.320.320.320.320.320.320.320.320.320.320.32Sub-<strong>to</strong>tal Dollar Amount <strong>of</strong> TobaccoCigarsThe in<strong>for</strong>mation collected or provided as part <strong>of</strong> <strong>the</strong> <strong>application</strong> process will only be used <strong>for</strong> purposes relating <strong>to</strong> <strong>the</strong> operation <strong>of</strong><strong>the</strong> relevant program. All in<strong>for</strong>mation you provide will be kept confidential and compliant with <strong>the</strong> Access <strong>to</strong> In<strong>for</strong>mation andProtection <strong>of</strong> Privacy Act.

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