Form R-5613 Pm - Participating Manufacturer'S Product - Schedule Of Cigarettes And Roll-Your-Own In Inventory - Product In Inventory

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R-5613 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 in Inventory
PRODUCT IN INVENTORY
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). Under Louisiana
law (LSA-R.S. 13:5061 et seq. and LSA-R.S. 13:5071 et seq.), you must file this schedule even if you report zero amounts on the lines. Complete this schedule and attach the original to your monthly Tobacco Tax Return (Form R-5604), and forward a copy of this
schedule to the Department of Justice, Tobacco Section, P.O. Box 94005, Baton Rouge, LA 70804-9005.
Beginning Inventory
Sticks:
Ounces:
Adjustments to Inventory
A
B
C
D
E
F
G
Vendor Purchased From
Manufacturer or First Importer
Date of
Number of Sticks
Ounces of
Product Country
Product Brand Name
Adjustment
of Cigarettes
Roll-Your-Own
of Origin
Name
City, State
Name
City, State
Subtotal (if additional sheet needed)
Total
*Please attach explanation(s) of adjustments. *
Physical Ending Inventory
A
B
C
D
E
F
Vendor Purchased From
Manufacturer or First Importer
Number of Sticks
Ounces of
Product Country
Product Brand Name
of Cigarettes
Roll-Your-Own
of Origin
Name
City, State
Name
City, State
Subtotal (if additional sheet needed)
Total
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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