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MISSOURI DEPARTMENT OF REVENUE

DLN

FORM

TAXATION DIVISION

4387

P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320

TOBACCO PRODUCTS TAX —

(REV. 11-2010)

OTHER THAN CIGARETTES

DUE ON OR BEFORE THE 15TH OF EACH MONTH FOLLOWING THE REPORT MONTH

COMPANY

LICENSE NO.

CALENDAR MONTH OF

STREET ADDRESS

TELEPHONE

(__ __ __) __ __ __ - __ __ __ __

CITY

STATE

ZIP CODE

___ ___ ___ ___ ___

LINES 1 THROUGH 24 ARE BASED ON THE MANUFACTURER’S INVOICE PRICE BEFORE DISCOUNTS AND/OR DEALS

INVENTORY

1. OPENING INVENTORY (LINE 6 FROM PREVIOUS MONTH’S RETURN) . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .

2. TOBACCO PRODUCTS (OTHER THAN CIGARETTES)

RECEIVED INTO STOCK DURING MONTH (FROM SCHEDULE A, FORM 4388) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. CUSTOMER RETURNS (FROM SCHEDULE B, FORM 4389)

(PRODUCTS RETURNED TO INVENTORY DURING MONTH) (SEE LINE 22 FOR CREDIT) . . . . . .. . . . . . . . . . . . .

4. TOTAL TOBACCO PRODUCTS AVAILABLE FOR SALE (SUM OF LINES 1, 2, AND 3) . . . . . . . . . . . . . . . . . . . . . . . . .

5. TOTAL MANUFACTURER’S INVOICE PRICE OF ALL PRODUCTS SOLD OR

REMOVED FROM INVENTORY DURING THE MONTH . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. ENDING INVENTORY (LINE 4 LESS LINE 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DEDUCTIONS — (NOT ALLOWED UNTIL PRODUCTS ARE SOLD OR REMOVED FROM INVENTORY AND INCLUDED IN LINE 5 ABOVE)

7. EXPORT SALES (FROM SCHEDULE C, FORM 4390) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8. MILITARY SALES (FROM SCHEDULE D, FORM 4390) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. PRODUCTS SOLD TO OTHER LICENSED WHOLESALERS (FROM SCHEDULE E, FORM 4390) . . . . . . . . . . . . . . . .

10. PRODUCTS RETURNED TO THE MANUFACTURER

(ATTACH REQUIRED CREDIT MEMO COPY — SEE INSTRUCTIONS ON REVERSE SIDE) . . . . . . . . . . . . . . . . . . . .

11. TAX-PAID PURCHASES FROM MISSOURI LICENSED WHOLESALERS (ATTACH COPY OF INVOICE) . . . . . . . . . .

12. OTHER (ATTACH DETAILED DOCUMENTATION — SEE INSTRUCTIONS ON REVERSE SIDE) . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13. TOTAL DEDUCTIONS (SUM OF LINES 7 THROUGH 12)

TAX CALCULATION

14. AMOUNT SUBJECT TO TAX (LINE 5 LESS LINE 13). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. CALCULATE TAX (MULTIPLY LINE 14 TIMES 10% [.10]) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16. TIMELY DISCOUNT (MULTIPLY LINE 15 TIMES 2% [.02]) (DISCOUNT IS FORFEITED IF NOT REMITTED TIMELY) . . . . . . . . . .

17. TOTAL TAX DUE (LINE 15 LESS LINE 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18. PENALTY (25% LATE PAYMENT) (LINE 17 TIMES 25%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19. TOTAL TAX AND PENALTY DUE (LINE 17 PLUS LINE 18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20. INTEREST (3% APR) (CALCULATE USING FIGURE ON LINE 19) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21. TOTAL AMOUNT DUE (LINE 19 PLUS 20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CREDITS — (CREDITS ARE ALLOWED ONLY TO THE EXTENT THAT TAX WAS PREVIOUSLY PAID)

22. PRODUCTS RETURNED TO INVENTORY (ENTER AMOUNT OF TAX PREVIOUSLY PAID ON THE

RETURNED PRODUCTS) (ATTACH REQUIRED DOCUMENTATION — SEE INSTRUCTIONS ON

REVERSE SIDE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23. PRODUCT RETURNED DIRECTLY TO MANUFACTURER BY RETAILER (ATTACH REQUIRED DOCUMENTATION—

SEE INSTRUCTIONS ON THE REVERSE SIDE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24. OTHER ADJUSTMENT CREDITS (VALID DOCUMENTATION MUST BE ATTACHED —

SEE INSTRUCTIONS ON REVERSE SIDE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25. TOTAL CREDITS (LINE 22 PLUS LINE 23 AND LINE 24) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TAX DUE

26. TOTAL BALANCE DUE (LINE 21 LESS LINE 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

I, do hereby certify under the penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and

is a complete and full presentation of all transactions from the best information available. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as

defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.

SIGNATURE

TITLE

DATE

__ __ / __ __ / __ __ __ __

Make check payable to MISSOURI DEPARTMENT OF REVENUE, and mail to: Taxation Division, Excise Tax, P.O. Box 3320, Jefferson City, MO 65105-

3320. If you have questions or need assistance in completing this form, please call (573) 751-5772 / TDD (800) 735-2966; or email excise@dor.mo.gov.

You may also obtain this form from the department’s web site at:

This publication is available upon request in alternative accessible format(s).

MO 860-1644 (11-2010)