Form 4258 - T-102 - Schedule Of Other Tobacco Products Credits (Adjustments)

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Michigan Department of Treasury
4258 (04-10)
T-102: Schedule of Other Tobacco Products Credits (Adjustments)
Important: Read the instructions on Page 2 before completing this schedule.
1. Name
2. Account Number (FEIN, ME or TR Number)
3. Michigan License Number
4. Reporting Period (MM/CCYY)
CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.
T-102a: Schedule of Non Tax-Paid Other Tobacco Product Credits
T-102b: Schedule of Tax Paid Other Tobacco Product Credits
Claim Filed Against:
NPM Roll-Your-Own (RYO) Tobacco Products
Claim/Credit Information
Purchase Entry (T-101)
14.
Manufactuer/Wholesaler/Unclassified
19. Total
Manufacturer
Brand
10.
Wholesale
Acquirer
Ounces per
Branch
Price
7. Credit
11. FEIN
12. Name
13. Type
15. FEIN
16. Name
17. Code
18. Name
5. Date
6. Number
8. Invoice Number
9. Tax Period
Code
entry
Types
21. TOTAL
20. TOTAL
$
ounces
Attach to your Michigan WT-100 and AT-100 forms.

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