Form 4257 - Attach To Your Michigan Wt-100 Or At-100 Forms

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Michigan Department of Treasury
4257 (Rev. 01-13)
T-103: Schedule of Out-of-State Other Tobacco Product Shipments (Michigan Based Licensees Exports Only)
Important: Read the instructions on Page 2 before completing this schedule.
1. Name
2. Account Number (FEIN, ME or TR Number)
3. Michigan License Number
4. Reporting Period (MM/CCYY)
Schedule of Other Tobacco Product Shipments to the State of:
NPM Roll-Your-Won (RYO) Tobacco Products
20. Total
Sold to Information
Address of Purchaser
Manufactuer
Brand
14.
19. Total
5. Date
6. Invoice
7. Invoice
8. Branch
Premium
Whole-
Ounces per
Sold
Date
Number
Code
Cigar Stick
sale Price
Entry
9. FEIN
10. Name
11. Type
12. City
13. State
15. FEIN
16. Name
17. Code
18. Name
Count (PC1)
22. TOTAL
23. TOTAL
21. TOTAL
$
ounces
PC1’S
Attach to your Michigan WT-100 or AT-100 forms.

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