Form 4405 - Cigarette Decal Purchase Order Form - Missouri Department Of Revenue - 2009

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DOR USE ONLY

MISSOURI DEPARTMENT OF REVENUE

FORM

DLN NUMBER _______________________________

TAXATION DIVISION

4405

P.O. BOX 811

INVOICE DATE _______________________________

JEFFERSON CITY, MISSOURI 65105-0811

PAYMENT DUE ON

CIGARETTE DECAL PURCHASE ORDER FORM

(REV. 11-2009)

CREDIT PURCHASES $ ______________________________

WHOLESALER

LICENSE NUMBER

STREET

CITY, STATE, ZIP CODE

E-MAIL

TELEPHONE NUMBER

FAX NUMBER

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

SHIPPING METHOD ( WHOLESALER MUST PAY)

PLEASE PROVIDE ACCOUNT NUMBER

PAYMENT TERMS FOR DECALS

UPS

____________________________________________________________

UPS NEXT DAY AIR

____________________________________________________________

CASH

FEDERAL EXPRESS PRIORITY OVERNIGHT

____________________________________________________________

CREDIT

FEDERAL EXPRESS STANDARD OVERNIGHT

____________________________________________________________

DHL

____________________________________________________________

ONLINE

PICK-UP

____________________________________________________________

OTHER (SHIPPER NOT LISTED ABOVE)

____________________________________________________________

NAME ___________________________________________________________________________________________________________________

COLUMN A

COLUMN B

COLUMN C

COLUMN D

COLUMN E

COLUMN F

COLUMN G

MISSOURI STATE

JACKSON COUNTY

ST. LOUIS COUNTY

NUMBER OF

STATE COST

JACKSON COUNTY

ST. LOUIS COUNTY

COST LESS

COST

ROLLS

FOR DECALS

COST FOR DECALS

APPLICABLE

(NO DISCOUNT

ORDERED—

(COLUMN A TIMES

(COLUMN B TIMES

(COLUMN C TIMES

DISCOUNT*

ALLOWED)

MUST BE FULL

NUMBER OF ROLLS

NUMBER OF ROLLS IN

DECAL DESCRIPTION

ROLLS

IN COLUMN D)

COLUMN D)

20 PACKS OF CIGARETTES

STATE STAMP — 4,000

$ 659.60

STATE STAMP — 30,000

$4,947.00

STATE/JACKSON COUNTY

$ 659.60

$ 196.00

STAMP — 4,000

STATE/JACKSON COUNTY

$4,947.00

$1,470.00

STAMP — 30,000

STATE/ST. LOUIS COUNTY

$ 659.60

$ 200.00

STAMP — 4,000

STATE/ST. LOUIS COUNTY

$4,947.00

$1,500.00

STAMP — 30,000

25 PACKS OF CIGARETTES

STATE STAMP — 4,000

$ 824.50

STATE/JACKSON COUNTY

$ 824.50

$ 245.00

STAMP — 4,000

STATE/ST. LOUIS COUNTY

$ 824.50

$ 250.00

STAMP — 4,000

COLUMN TOTALS

(COLUMN E)

(COLUMN F)

(COLUMN G)

1. JACKSON COUNTY SUBTOTAL DUE (COLUMN F) . . . . .$

7. STATE SUBTOTAL DUE (COLUMN E) . . . . . . . . . . . . . . . .$

2. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) . . .$

8. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) . . .$

3. TOTAL DUE JACKSON COUNTY . . . . . . . . . . . . . . . . . . .$

9. TOTAL DUE STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

10. LESS PAYMENT RECEIVED WITH PURCHASE ORDER .$

4. SUBTOTAL DUE ST. LOUIS COUNTY (COLUMN G) . . . . .$

5. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) . . .$

6. TOTAL DUE ST. LOUIS COUNTY . . . . . . . . . . . . . . . . . . . .$

TOTAL AMOUNT DUE ON STATE DECALS**

TOTAL AMOUNT DUE ON COUNTY DECALS **

(TOTAL FROM LINE 9 MINUS LINE 10)

(TOTAL OF LINES 3 AND 6 — MUST BE PAID AT TIME OF PURCHASE)

(CREDIT PURCHASES MUST BE PAID BY 15TH OF NEXT MONTH)

COUNTY CHECK NO.

STATE CHECK NO.

*IF DISCOUNT IS DISALLOWED, COST WILL BE ADJUSTED BY ADDING 3% TO STATE COST AND 2% TO JACKSON COUNTY COST

**SEPARATE CHECKS MUST BE SUBMITTED FOR STATE AND COUNTY

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 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 OF PERSON COMPLETING DECAL ORDER FORM

PRINT NAME

DATE

__ __ / __ __ / __ __ __ __

SEND TO: TAXATION DIVISION, EXCISE TAX, P.O. BOX 811, JEFFERSON CITY, MISSOURI 65105-0811. If you have questions or need assistance in completing this form, please call

(573) 751-7163 or email excise@dor.mo.gov. You may also obtain this form from the department’s web site at: TDD (800) 735-2966

MO 860-2574 (11-2009)

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