Form 4259 - T-101 - Schedule Of Other Tobacco Product Purchases- 2010 printable pdf download

Form 4259 - T-101 - Schedule Of Other Tobacco Product Purchases- 2010

Michigan Department of Treasury

4259 (04-10)

T-101: Schedule of Other Tobacco Product Purchases (Receipts)

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)

CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.

T-101a: Schedule of Tax-Unpaid Other Tobacco Product Purchases for Michigan (Michigan based licensees only)

T-101b: Schedule of Michigan Tax Paid Other Tobacco Product Purchases (Wholesalers only)

T-101c: Schedule of Returned Tax Paid Other Tobacco Product from Michigan customers

NPM Roll-Your-Own (RYO) Tobacco Products

19. Total

Purchased from Information

Address of Seller

Manufacturer

Brand

5. Date

6. Invoice

7. Invoice

8. Branch

14. Wholesale

Ounces per

Received

Date

Number

Code

Price

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 and AT-100 Forms.

Form 4259 - T-101 - Schedule Of Other Tobacco Product Purchases- 2010