Form R-5612 Pm - Participating Manufacturer'S Product - Schedule Of Cigarettes And Roll-Your-Own Sold Outside Louisiana - Non-Louisiana Sales

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R-5612 PM (11/13)
PM
This schedule is due with the monthly tax return during which
Participating Manufacturer’s Product
the cigarettes or “roll-your-own” were reported.
Filing Period
Schedule of Cigarettes and
Contact Person
Roll-Your-Own Sold Outside Louisiana
NON-LOUISIANA SALES
Telephone Number
FEIN
Account Number
Name
Address
Instructions are on the reverse side and are available on the Louisiana Department of Revenue’s website under Forms. The information on this schedule is required to comply with Louisiana laws relating to the Master Settlement Agreement (“MSA”). You must file
this schedule even if you report zero amounts. Complete this schedule and attach the original to your monthly Tobacco Tax Return (Form R-5604), and forward a copy of this schedule, along with a computer printout of the brands and quantities of all sales of PM
cigarettes and roll-your-own to a jurisdiction other than Louisiana that occurred in the calendar month being reported, to the Department of Justice, Tobacco Section, P.O. Box 94005, Baton Rouge, LA 70804-9005.
A
B
C
D
E
F
G
H
I
J
Tax Value of Stamps
Number of
Stamp Affixed
Vendor Purchased From
Manufacturer or First Importer
Ounces of
Dollar Amount of
Product Country
Product Brand Name
Placed
State
Sticks of
Roll-Your-Own
Roll-Your-Own
of Origin
Yes
No*
Name
City, State
Name
City, State
on Cigarettes
Cigarettes
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
Subtotal (if additional
.00
.00
sheet needed)
Total
.00
.00
*If “No” was indicated in Column D above, please provide an explanation on a separate sheet to detail the reason why no tax stamp was affixed to the product.
I swear, under penalty of perjury, that the above information is true and correct. By signing below, I acknowledge that I am the individual who prepared this form and have the authorization to submit such on behalf of the aforementioned entity.
Signature of Preparer
Print Name of Preparer
Title of Preparer
Date
(mm/dd/yyyy)

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