Form 4341 - Other Tobacco Products Summary First Sale Retailers Monthly Report Of Purchases
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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4341
P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320
OTHER TOBACCO PRODUCTS SUMMARY
FIRST SALE RETAILERS
(REV. 07-2011)
MONTHLY REPORT OF PURCHASES
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
___ ___ ___ ___ ___
1. Other tobacco products received from out-of-state suppliers not licensed in
Missouri (Attach completed Form 4343) .............................................................................................
1
$
2. EXEMPTIONS:
2A. Export Sales (Attach completed Form 4795, Schedule A)
Two copies required for each state ........................................
2A
$
2B. Products returned to manufacturer
(Attach copy of Credit Memo) ................................................
2B
$
Total (Lines 2A and 2B) .......................................................................................................................
2
$
3. Taxable other tobacco products (Line 1 less Line 2) ...........................................................................
3
$
4. Tax (Computed at 10% of Line 3) ........................................................................................................
4
$
5. Less timely remittance discount (2% of Line 4) (Forfeited if not timely remitted) .................................
5
$
6. Total tax due (Line 4 less Line 5) .........................................................................................................
6
$
7. Penalty (25% late payment) .................................................................................................................
7
$
8. Total tax and penalty due (Line 6 plus Line 7) .....................................................................................
8
$
9. Interest (3% APR) (Compute using total from Line 8) ..........................................................................
9
$
10. Credit from previous report (Attach copy) ............................................................................................
10
$
11. TOTAL DUE (Line 8 plus Line 9 minus Line 10)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
$
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. 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. 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
TITLE
DATE
__ __ / __ __ / __ __ __ __
REPORT MUST BE ACCOMPANIED BY FULL REMITTANCE OF TOTAL DUE (LINE 11)
Make check payable to MISSOURI DEPARTMENT OF REVENUE, and mail to: Taxation Division, Excise Tax, P.O. Box
If you have questions or need assistance in completing this form, please call
3320, Jefferson City, Missouri 65105-3320.
(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 860-2531 (07-2011)
DOR-4341 (07-2011)
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