DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
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TAXATION DIVISION
4342
P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320
OTHER TOBACCO PRODUCTS
(REV. 05-2011)
MONTHLY REPORT — OUT-OF-STATE
WHOLESALERS SELLING INTO MISSOURI
DUE ON OR BEFORE THE 15TH OF EACH MONTH FOLLOWING THE REPORT MONTH
COMPANY
LICENSE NO.
MONTH/YEAR
___ ___ / ___ ___ ___ ___
STREET ADDRESS
TELEPHONE
(__ __ __) __ __ __ - __ __ __ __
CITY
STATE
ZIP CODE
___ ___ ___ ___ ___
LIST ALL TOBACCO PRODUCTS DISTRIBUTED OR DELIVERED INTO MISSOURI
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MANUFACTURER’S INVOICE PRICE
INVOICE DATE
INVOICE NUMBER
CONSIGNEE
ADDRESS
(BEFORE DISCOUNTS AND/OR DEALS)
_ _ / _ _ / _ _ _ _
$
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
$
1. Total manufacturer’s invoice price (All products distributed or delivered into Missouri)
1
2. EXEMPTIONS:
2A. Product returned from Missouri retail customers (Complete
$
Schedule B on reverse side)
2A
$
2B. Military sales (Complete Schedule D on reverse side)
2B
2C. Sales to other Missouri licensed wholesalers
$
(Complete Schedule E on reverse side)
2C
$
TOTAL (Lines 2A, 2B and 2C) ...............................................................................................................
2
$
3. Taxable other tobacco products (Line 1 less Line 2) .............................................................................
3
$
4. Multiply Line 3 by 10% ...........................................................................................................................
4
$
5. Less 2% timely payment discount (Line 4 times 2%) (Forfeited if not timely remitted) ..........................
5
$
6. Total tax due (Line 4 less Line 5) ...........................................................................................................
6
$
7. Penalty (25% late penalty) (Line 6 times 25%) ......................................................................................
7
8. Total tax and penalty due (Line 6 plus Line 7) .......................................................................................
8
$
9. Interest (3% APR) (Calculate using figure on Line 8) ............................................................................
9
$
$
10. Less credit (Attach letter of credit) .........................................................................................................
10
11. Less credit for product returned directly to manufacturer by retailer (Attach tax affidavit from
$
manufacturer and refund/credit memo to retailer ...................................................................................
11
12. TOTAL DUE (Line 8 plus Line 9, minus Line 10 and Line 11) ...............................................................
12
$
I do hereby certify under the penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and is a complete and full presentation of all
transactions from the best information available. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for
any tax exemption, credit or abatement if I employ such aliens.
SIGNATURE
PRINT NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
REPORT MUST BE ACCOMPANIED BY FULL REMITTANCE OF TOTAL DUE (LINE 11)
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
Make check payable to MISSOURI DEPARTMENT OF REVENUE, and mail to: Taxation Division, Excise Tax, P.O. Box 3320, Jefferson City, Missouri
65105-3320. If you have questions or need assistance in completing this form, please call (573) 751-5772 (TDD 1-800-735-2966) or e-mail excise@dor.mo.gov.
You may also access this form from the Department’s web site:
This publication is available upon request in alternative accessible format(s).
MO 860-2530 (05-2011)