Form 4856 - Monthly Pact Act Report - Tobacco Sales Report
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2Michigan Department of Treasury
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4856 (Rev. 06-11)
Monthly Pact Act Report — Tobacco Sales Report
Issued under federal law Title 15 U.S. Code 375-378.
Reporting Period (Month/Year)
PART 1: IdenTIfy BuSIneSS
Federal Employer Identification Number (FEIN)
Business Name
Mailing Address (Number and Street)
License Number
Business Telephone Number
City
State
ZIP Code
Country/Territory
Contact Telephone Number
Contact Name
E-mail Address
PART 2: IdenTIfy SAleS InTo MIchIgAn
— Attach additional sheets as needed.
Invoice Number
Invoice Date
Buyer Name
Buyer Address
Deliverer Telephone Number
Deliverer Name
Deliverer Address
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Brand
UPC
Type (Check one)
Smokeless
Package Size
Quantity
Wholesale Price
Roll-Your-Own
Continue and Sign on Page 2
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