Form 4916 - Licensee'S Monthly Report Of Cigarettes And Roll-Your-Own Tobacco - Missouri Department Of Revenue

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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
Print Form
(REV. 05-2008)
AND ROLL-YOUR-OWN TOBACCO
FOR THE MONTH OF _______________________________________________ YEAR ________________
Wholesalers on a deferred payment basis and retailers who purchase from unlicensed suppliers 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. Wholesalers list all cigarettes stamped by your company for sale in Missouri and all ounces of roll-your-own
tobacco products sold in Missouri. Retailers list all roll-your-own tobacco products purchased from unlicensed suppliers for sale in Missouri. (ATTACH COPIES OF INVOICES FOR ANY
NON-PARTICIPATING MANUFACTURER’S BRANDS.) THIS REPORT MUST BE FILED, EVEN IF NO ACTIVITY OCCURRED DURING THE REPORTING PERIOD.
BUSINESS NAME
LICENSE NUMBER
___ ___ ___ ___
ADDRESS
CONTACT PERSON
CITY
STATE
ZIP
TELEPHONE NUMBER
___ ___ ___ ___ ___- ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
A
B
C
D
E
Number of Cigarette (sticks)
Ounces of Roll-Your-Own Tobacco
For Each Brand, List the Complete Name
For Each Brand, List the Name and Address of the Person
Full Brand Name
Stamped for Sale in Missouri
and Address of the Manufacturer
on Which Tobacco Tax was Paid
From Whom Each Brand was Purchased
Name
Street Address
Name
Street Address
City
State
City
State
__ __ __ __ __ __ __ __
Sticks
_________________
Ounces
Zip
Country
Zip
Country
Name
Street Address
Name
Street Address
City
State
City
State
__ __ __ __ __ __ __ __
Sticks _________________
Ounces
Zip
Country
Zip
Country
Name
Street Address
Name
Street Address
City
State
City
State
__ __ __ __ __ __ __ __
Sticks
_________________
Ounces
Zip
Country
Zip
Country
If additional space is needed, continue on back or attach a list.
I SWEAR UNDER PENALTY OF PERJURY, THAT I HAVE KNOWLEDGE OF THE FACTS REPRESENTED IN THIS REPORT, THAT THEY ARE COMPLETE AND ACCURATE, THAT THE DOCUMENT IS PREPARED PURSUANT TO THE PUBLIC DUTY PRESCRIBED
BY MISSOURI LAW, AND THAT I HAVE THE AUTHORITY TO MAKE THESE REPRESENTATIONS ON BEHALF OF THE ABOVE-NAMED LICENSEE.
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 (05-2008)
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