Form 4855 - Monthly Pact Act Report - Cigarette Sales Report Page 2
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24855, Page 2
Invoice Number from Page 1
FEIN from Page 1
Reporting Period from Page 1
PARt 3: CeRtIfICAtIon
Under penalty of perjury, I verify I examined this report, and, to the best of my knowledge, it is true, correct and complete. I also verify such information
is taken from the books and records of the business for which this return is filed.
Signature of Owner/Officer
Phone Number
Title
Date
Signature of Owner/Officer
Phone Number
Title
Date
InStRuCtIonS foR foRM 4855,
Monthly Pact Act Report — Cigarette Sales Report
If you are a person who sells, transfers or ships cigarettes into the state of Michigan, you are required by federal
Law to file this report (Form 4855) with the state of Michigan. For additional information, see the Prevent All Cigarette
Trafficking (PACT) Act at 15 USC 376. Note that sales of roll-your-own tobacco or smokeless tobacco must be reported
on Form 4856.
Complete this report to show each invoice reflecting a sale of cigarettes into Michigan and every brand and quantity of
cigarettes listed on each of those invoices.
This report is due by the 10th day of the month following the month in which the cigarettes were shipped. Mail the
completed report to:
Tobacco Tax Unit
Michigan Department of Treasury
P.O. Box 30474
Lansing, MI 48909
It is important to note that other requirements of Michigan law may apply to persons who sell or plan to sell cigarettes
or other tobacco products in, or into, Michigan. These requirements may include, but are not limited to, licensing and
stamping of tobacco products. Note, too, that Michigan imposes serious penalties on those who violate these laws. If you
have any questions about your responsibilities, contact the Tobacco Tax Unit at (517) 636-4630.
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