Reset Form
Print Form
MONTH OF
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
, 20
783
P.O. BOX 811, JEFFERSON CITY, MO 65105-0811
LICENSE NUMBER
EXPORT OF STAMPED CIGARETTES
(REV. 05-2011)
REPORT - SCHEDULE E
WHOLESALER NAME
ADDRESS
CIGARETTES TRANSFERRED FROM MISSOURI INTO (CONSIGNEE STATE OR COUNTRY)
If you have questions or need assistance in completing this form, please call (573) 751-7163 (TDD 1-800-735-2966)
or e-mail excise@dor.mo.gov. You may also access this form from the Department’s web site:
INSTRUCTIONS:
1. Complete (in triplicate) Form 783 for each state.
2. Attach original and duplicate to the Consolidated Monthly Cigarette Tax Report (Form 265-20 and/or Form 265-25). Retain third copy
for your file.
NOTE: CSR 10-16.150(3) — A licensed cigarette wholesaler may possess packages of cigarettes designated for export if a tax stamp or
meter impression required by another state is affixed to such packages of cigarettes and such packages are stored separately and
distinct from Missouri tax stamped cigarettes.
INVOICE
TO WHOM SOLD OR TRANSFERRED
NUMBER OF PACKAGES
NUMBER OF PACKAGES
DATE
(NAME, STREET ADDRESS, CITY, STATE)
NUMBER
OF CIGARETTES – 25s
OF CIGARETTES – 20s
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
Enter total here and on Line 15 of Form 265-20 and/or Form 265-25
0
0
or if necessary continue on reverse side of this form. .................................................................................
This publication is available upon request in alternative accessible format(s).
MO 860-1454 (05-2011)