Form 4343 - Other Tobacco Products Receipts Schedule Retailer Purchases From Unlicensed Out-Of-State Suppliers 4343 Page 2

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FORM 4343

PAGE 2

Enter TOTAL from Form 4343, page 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MANUFACTURER’S INVOICE PRICE

INVOICE DATE

INVOICE NUMBER

PURCHASED FROM

ADDRESS (CITY, STATE, ZIP)

(BEFORE DISCOUNTS AND/OR DEALS)

_ _ / _ _ / _ _ _ _