Form 267 - Common Carrier Monthly Report Cigarette Tax

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MISSOURI DEPARTMENT OF REVENUE
MONTH OF
FORM
TAXATION DIVISION
267
P.O. BOX 811, JEFFERSON CITY, MO 65105-0811
, 20
COMMON CARRIER MONTHLY REPORT CIGARETTE TAX
(REV. 05-2011)
NAME
FEDERAL IDENTIFICATION NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
CONSIGNOR
DELIVERY
PACKAGES OF CIGARETTES
CONSIGNOR
POINT OF ORIGIN
CONSIGNEE
POINT OF DELIVERY
INVOICE NUMBER
DATE
DELIV.
REFUSED RETURNED
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_ _ / _ _ /_ _ _ _
_ _ / _ _ /_ _ _ _
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_ _ / _ _ /_ _ _ _
_ _ / _ _ /_ _ _ _
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If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov.
You may also obtain this form from the Department’s web site at: TDD (800) 735-2966
I, THE UNDERSIGNED LEGAL REPRESENTATIVE OF THE ABOVE-NAMED COMMON CARRIER, STATE UPON MY OATH THAT THIS REPORT IS TRUE AND CORRECT TO
THE BEST OF MY KNOWLEDGE.
NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
This publication is available upon request in alternative accessible format(s).
DOR-267 (05-2011)
MO 860-1445 (05-2011)

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