Form 4855 - Monthly Pact Act Report - Cigarette Sales Report

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Michigan Department of Treasury
Reset Form
4855 (Rev. 06-11)
Monthly Pact Act Report — Cigarette 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
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Brand
UPC
Cigarette (Sticks)
Continue and Sign on Page 2

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