Form 4257 - T-103 - Schedule Of Out-Of-State Other Tobacco Product Shipments - 2010

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Michigan Department of Treasury
4257 (Rev. 04-10)
T-103: Schedule of Out-of-State Other Tobacco Product Shipments (Michigan Based Licensees Exports Only)
Important: Read the instructions on Page 2 before completing this schedule.
1. Name
2. Account Number (FEIN, TR or ME Number)
3. Michigan License Number
4. Reporting Period (MM/CCYY)
Schedule of Other Tobacco Product Shipments to the State of:____________________________________
NPM Roll-Your-Own (RYO) Tobacco Products
19. Total
Sold to Information
Address of Purchaser
Manufacturer
Brand
5. Date
6. Invoice
7.Invoice
8.Branch
14. Wholesale
Ounces per
Price
Sold
Date
Number
Code
9. FEIN
10. Name
11. Type
12. City
13. State
15.FEIN
16. Name
17. Code
18. Name
Entry
21. TOTAL
$
20. TOTAL
ounces
Attach to your Michigan WT-100, AT-100 or ST-100 Forms.

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