Form
Indiana Department Of Revenue
For Department Use Only
OTP-M
Other Tobacco Products Monthly Return
Date Received:
State Form 46853
(317) 615-2710
(R / 06-12)
Received By:
This Return Must Be Filed Each Month Within 15 Days Of The Last Day Of The Month Being Reported
Name of Company
Federal ID Number
License #
Month and Year of
Return
Taxpayer ID Number
E-mail Address
Mail Completed Form to:
Indiana Department of Revenue
P.O. Box 901
Indianapolis, IN 46206-0901
(A)
(B)
Tobacco Products
Moist Snuff
(wholesale price)
(ounces)
Taxable Tobacco
1. Purchases/Shipments Of Tobacco Products (From OTP-Schedule 1 Category A)
$
Deductions
2. Tobacco Products Shipped Out-Of-State (From OTP-Schedule 1 Category B)
$
3. Tobacco Products Returned To Manufacturer (From OTP-Schedule 1 Category C)
$
4. Sales To Federal Government (From OTP-Schedule 1 Category D)
$
5. Tax Paid Purchases (From OTP-Schedule 1 Category E)
$
6. Untaxed Sales To Indiana Distributor (From OTP-Schedule 1 Category F)
$
7. Bad Debt Deduction (From OTP-Schedule 3)
$
8. Total Deductions (Sum Of Lines 2-7)
$
9. Taxable Tobacco After Deductions (Line 1 Minus Line 8)
$
Tax Due
10. Tax On Tobacco Products Per Column (Multiply Line 9A X .24,
Multiply Line 9B X .40)
$
$
11. Total Tax On Tobacco Products (Sum Of Line 10A And 10B Column Totals)
$
12. Less Collection Allowance (Multiply Line 11 X .006. Only Allowed If Timely Filed.)
$
13. Tax Due Or Refund (Line 11 Minus Line 12)
$
14. Penalty (10% Of Tax Due Or $5.00 Whichever Is Greater If Filed Late)
$
15. Interest (At Current Rate)
$
16. Total With Penalty And Interest (Sum Lines 13, 14, & 15 If Applicable)
$
17. Refund Claimed
$
18. Total Remittance (Attach Check Or Money Order)
$
I hereby declare under penalties of perjury that the information contained in this return, including accompanying schedules and state-
ment, is true, correct, and complete to the best of my knowledge and belief.
Signature Of Taxpayer Or Agent
Printed Name Of Taxpayer Or Agent
Title
Telephone Number
Date