Form 4790 - United States Importers Cigarette Sales To Missouri Wholesalers Monthly Tax Report

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Missouri Department of Revenue
Document Locator Number
Form
United States Importers Cigarette Sales to
4790
Missouri Wholesalers Monthly Tax Report
r
Select Here If Amended Report
Company Name
Month/Year
License Number
Telephone Number
Fax Number
__ __ /__ __ __ __
(__ __ __)__ __ __-__ __ __ __
(__ __ __)__ __ __-__ __ __ __
Street Address
City
State
ZIP Code
Federal Employers Identification Number
List Name of Missouri Licensed Wholesaler
Customer’s MO
Number of 10
Number of 20
Number of 25
Total Number of
Invoice Number
Invoice Date (MM/DD/YYYY)
Purchasing Unstamped Cigarettes
License Number
Packs Sold
Packs Sold
Packs Sold
Packages Sold
__ __ /__ __ /__ __ __ __
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__ __ /__ __ /__ __ __ __
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__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
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Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Print Name
Title
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 4790 (Revised 05-2014)
Mail to: Taxation Division
Phone: (573) 751-7163
P.O. Box 811
Fax: (573) 522-1720
Visit
Jefferson City, MO 65105-0811
TTY: (800) 735-2966
for additional information.
E-mail:
excise@dor.mo.gov

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