DATE RETURNED
CREDIT/REFUND
CREDIT/REFUND
FROM WHOM RETURNED
MANUFACTURER’S INVOICE PRICE
INTO STOCK
NUMBER
DATE
(NAME AND ADDRESS)
(BEFORE DISCOUNTS AND/OR DEALS)
Enter total from Form 4389, page 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
_ _ / _ _ / _ _ _ _
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__ __ / __ __ / __ __ __ __
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_ _ / _ _ / _ _ _ _
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_ _ / _ _ / _ _ _ _
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__ __ / __ __ / __ __ __ __
_ _ / _ _ / _ _ _ _
__ __ / __ __ / __ __ __ __
_ _ / _ _ / _ _ _ _
__ __ / __ __ / __ __ __ __
Enter total here and on Line 3 of Form 4387 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
MO 860-2875 (11-2007)