Form 4916 - Licensee'S Monthly Report Of Cigarettes And Roll-Your-Own Tobacco - 2006

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FORM

MISSOURI DEPARTMENT OF REVENUE

4916

P.O. BOX 811, JEFFERSON CITY, MO 65105-0811

LICENSEE’S MONTHLY REPORT OF CIGARETTES

(REV. 11-2006)

AND ROLL-YOUR-OWN TOBACCO

FOR THE MONTH OF _______________________________________________ YEAR ________________

Wholesalers on a deferred payment basis must file this report on or before the fifteenth (15th) day of the month. Wholesalers on a cash basis must file this report on or before the twentieth (20th)

day of the month. List all cigarettes purchased and stamped by your company for sale in Missouri and all ounces of roll-your-own tobacco products purchased for sale in Missouri. (ATTACH

COPIES OF INVOICES FOR ANY NON-PARTICIPATING MANUFACTURER’S BRANDS.)

BUSINESS NAME

LICENSE NUMBER

ADDRESS

CONTACT PERSON

CITY

STATE

ZIP

TELEPHONE NUMBER

For Each Brand Purchased,

Number of Cigarettes

Ounces of Roll-Your-Own Tobacco

For Each Brand Purchased, List the Name

Brand Name

List the Name and Address of

Purchased for Sale in Missouri

and Address of the Manufacturer

the Supplier

If additional space is needed, attach a list.

I SWEAR UNDER THE PENALTY OF PERJURY THAT THE ABOVE NAMED LICENSEE HAS FOR THE REPORTING PERIOD STATED ABOVE, ONLY SOLD CIGARETTES OR ROLL-YOUR-OWN TOBACCO PRODUCTS INTO MISSOURI WHICH HAVE BEEN

PURCHASED FROM THE IDENTIFIED SUPPLIERS/MANUFACTURERS LISTED ON THIS REPORT.

SIGNATURE

PRINT NAME

TITLE

DATE

Mail report to: Missouri Department of Revenue, P.O. Box 811, Jefferson City, MO 65105-0811.

If you have questions or need assistance in completing this form, please call (573) 751-7163 or email excise@dor.mo.gov.

You may also obtain this form from the department’s web site at: TDD (800) 735-2966

This publication is available upon request in alternative accessible format(s).

MO 860-2969 (11-2006)