Form 304 Cigarette Tax Stamp Record Schedule C

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MONTH OF
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
304
P.O. BOX 811, JEFFERSON CITY, MO 65105-0811
CIGARETTE TAX STAMP RECORD —
, 20
(REV. 11-2007)
SCHEDULE C
WHOLESALER
LICENSE NUMBER
COMPLETE EACH SECTION AND TRANSFER TOTALS TO THE CONSOLIDATED MONTHLY CIGARETTE TAX REPORT (FORM 265)
If you have questions or need assistance in completing this form, please call (573) 751-7163 (TDD 1-800-735-2966)
or e-mail excise@dor.mo.gov. You may also access this form from the Department’s web site:
CHECK THE TYPE OF PACKS YOU WILL REPORT ON THIS SCHEDULE — ONE TYPE ON A SCHEDULE.
TWENTY PACKS
TWENTY-FIVE PACKS
SECTION 1 — STAMPS PURCHASED — LIST NUMBER OF PACKS FOR EACH TYPE OF DECAL
(C) STATE &
(D) STATE &
(E) OTHER
(B) STATE
INVOICE
DATE
ST. LOUIS COUNTY
JACKSON COUNTY
STATES*
ONLY
NUMBER
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
TOTALS
0
0
0
0
ALSO ENTER ON
FORM 265 OR 4426
SECTION 2 — STAMPS RECEIVED FOR CREDIT ON STAMPED CIGARETTES RETURNED TO THE MANUFACTURER, ETC. — LIST
NUMBER OF PACKS FOR EACH TYPE OF DECAL
(C) STATE &
(D) STATE &
(E) OTHER
INVOICE
(B) STATE
DATE
ST. LOUIS COUNTY
JACKSON COUNTY
STATES*
NUMBER
ONLY
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
TOTALS
0
0
0
0
ALSO ENTER ON
FORM 265 OR 4426
SECTION 3 — STAMPS USED (AFFIXED) — ON LAST BUSINESS DAY OF THE MONTH, ENTER TOTAL DECALS USED DURING
THE MONTH FOR EACH TYPE.
/
/
LAST BUSINESS DATE:
(B) STATE
(C) STATE &
(D) STATE &
(E) OTHER
ONLY
ST. LOUIS COUNTY
JACKSON COUNTY
STATES*
TOTALS
ALSO ENTER ON
0
0
0
0
FORM 265 OR 4426
*
ONLY IN-STATE WHOLESALERS ARE REQUIRED TO COMPLETE COLUMN TITLED “OTHER STATES.”
This publication is available upon request in alternative accessible format(s).
MO 860-1448 (11-2007)

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