Form 4126 - Equity Assessment Prepayment Report For Non-Participating Manufacturers (Npms) Of Cigarettes And/or "Roll-Your-Own" Tobacco Page 2
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2Form 4126 , Page 2
Instructions for Completing Form 4126, Equity Assessment Prepayment Report
for Non-Participating Manufacturers (NPMs) of Cigarettes and/or "Roll-Your-Own" Tobacco
Form 4126, Equity Assessment Prepayment Report for Non-Participating Manufacturers (NPMs) of Cigarettes and/or "Roll-Your-Own"
Tobacco must be completed and submitted with payment (along with any escrow requirements - see P.A. 244 of 1999 and MCL 205.426c)
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before your organization's product can be sold in Michigan . Violations of MCL 205.426c and MCL 205.426d may result in civil fines
and the tobacco product may be seized.
Cigarette Definition
The definition of a "cigarette" is taken from P.A. 244 of 1999.
CONTACT INFORMATION
Enter the year that this prepayment report covers on page one.
Lines 1-8. Enter your organization's name, tax identification number, telephone number and complete address, including name of country if
other than the United States.
Line 9. Enter the date that your organization began or will begin selling cigarettes or "Roll-Your-Own" tobacco in Michigan or to a distributor
who will ship into Michigan.
Lines 10-16. Enter the name, address, and telephone number of the resident agent. P.A. 327 of 1993, as amended, requires that a
non-participating manufacturer appoint and continually engage a resident agent for service of process. That service shall constitute legal
and valid service of process on the non-participating manufacturer. The department must be notified of any change regarding the resident
agent.
Family Name and UPC Code
Line 17: Enter the brand family name and UPC Code of the tobacco product to be sold in Michigan. Do not include styles. Indicate if the
tobacco product is cigarette or "roll-your-own" tobacco.
Line 18: The equity assessment prepayment amount that was determined by the department was based on anticipated sales in Michigan for
the previous year, or $10,000, whichever is greater. For purposes of calculating the equity assessment, .09 ounces of "roll-your-own" equals
one cigarette. Submit the full payment along with this completed report prior to selling cigarettes and/or Roll-Your-Own in Michigan to:
Michigan Department of Treasury
Special Taxes Division
P.O. Box 30474
Lansing, MI 48909-7974
Questions can be directed to (517) 636-4630.
Forms can be faxed to (517) 636-4631.
CERTIFICATION
Enter the name, title, address, name of country if other than the United States, and telephone number of an officer of the non-participating
manufacturer. The officer must sign and date the form attesting to the information provided on the form.
Once all required criteria are met, qualifying Non-Particiating Manufacturers and their identified brand families will be listed on Treasury's
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Web site ( ) as authorized. Please note that licensed Wholesalers and Unclassified Acquirers are required
to check the Web site list before they purchase or affix the appropriate stamp required by P.A. 327 of 1993, as amended.
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