Form 4791 - Tobacco Products - Other Than Cigarettes Retailer Tax-Paid Purchases From Missouri Licensed Wholesalers - Schedule F

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MISSOURI DEPARTMENT OF REVENUE
TAXATION BUREAU
FORM
P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320
4791
TOBACCO PRODUCTS — OTHER THAN CIGARETTES
PAGE
OF
RETAILER TAX-PAID PURCHASES FROM MISSOURI
(REV. 11-2007)
LICENSED WHOLESALERS — SCHEDULE F
COMPANY
LICENSE NO.
MONTH/YEAR
__ __ / __ __ __ __
LIST ALL TOBACCO PRODUCTS PURCHASED TAX-PAID FROM MISSOURI LICENSED WHOLESALERS
MANUFACTURER’S INVOICE PRICE
INVOICE DATE INVOICE NUMBER
FROM WHOM PURCHASED
ADDRESS (CITY, STATE, ZIP)
(BEFORE DISCOUNTS AND/OR DEALS)
$
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$
Enter total here and on Line 2 of Form 4341 or continue on reverse side . . .. . . . . . . . . . . . . . . . . . . . . .
If you have questions or need assistance in completing this form, please call (573) 751-5772 or email excise@dor.mo.gov.
You may also obtain this form from the department’s web site at: TDD (800) 735-2966
MO 860-2859 (11-2007)
This publication is available upon request in alternative accessible format(s).

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