Form 4126 - Equity Assessment Prepayment Report For Non-Participating Manufacturers (Npms) Of Cigarettes And/or "Roll-Your-Own" Tobacco
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1
2Michigan Department of Treasury
4126 (Rev. 11-10)
Reset Form
Equity Assessment Prepayment Report for Non-Participating
Manufacturers (NPMs) of Cigarettes and/or "Roll-Your-Own" Tobacco
Issued under authority of P.A. 327 of 1993, as amended.
The report covers sales from January 1, _______ through December 31, _______. Form and prepayment are due prior to selling
cigarettes and/or Roll-Your-Own tobacco in Michigan. NPMs that fail to comply will not appear on Treasury's Web site
( ) as an authorized NPM.
CONTACT INFORMATION
1. Manufacturer Name
2. FE, ME, or TR No. (if applicable)
3. Address
4. Business Telephone Number
5. City
6. State
7. Postal Code
8. Country
9. Date began or will begin selling in Michigan
10. Resident Agent Name
11. Telephone Number of Resident Agent
12. Address
13. City
14. State
15. Postal Code
16. Country
17. Indicate the brand Family name and the UPC code of the tobacco product and whether the product is cigarette or RYO. Attach
additional sheets as needed.
Brand Family Name
UPC Code
Cigarette or "Roll-Your-Own" (RYO) Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Cigarette
RYO Tobacco
Note: An NPM must notify the department when brands not included on this list will be sold in Michigan or if brands are discontinued
during the year.
18. Equity Assessment Prepayment Amount Due by March 1st or prior to selling cigarettes or
Roll-Your-Own in Michigan.
(a minimum of $10,000 or the amount Determined by the Treasury Department)
18.
CERTIFICATION
I declare under penalty of perjury that the information contained in this report and any attachments is true and correct to the best of my
knowledge. I further declare my intent to comply with Public Act 244 of 1999, and sections 6c and 6d of Public Act 327 of 1993, as
amended.
Officer Name
Title
Address
City
State
Postal Code
Country
Officer Signature
Date
Phone Number
When completed, mail a copy of the form to: Michigan Department of Treasury, Special Taxes Division, P.O. Box 30474
Lansing, MI 48909-7974. The Tobacco Taxes Unit can be reached at (517) 636-4630 or faxed at (517) 636-4631.
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