Form 4258 - T-102 Schedule Of Other Tobacco Products Credits (Adjustments)

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Michigan Department of Treasury
4258 (Rev. 01-13)
T-102: Schedule of Other Tobacco Products Credits (Adjustments)
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 TYPES:
CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.
T-102a: Schedule of Non Tax-Paid Other Tobacco Product Credits
T-102b: Schedule of Tax Paid Other Tobacco Product Credits
NPM Roll-Your-Won (RYO) Tobacco Products
Claim Filed Against:
20. Total
Claim/Credit Information
Purchase Entry (T-101)
10.
Manufactuer/Wholesaler/
14.
Manufactuer
Brand
19. Total
Premium
Unclassified Acquirer
Branch
Whole-
Ounces per
Cigar Stick
7. Credit
Code
sale Price
Entry
5. Date
6. Number
8. Invoice Number
9. Tax Period
11. FEIN 12. Name 13. Type
15. FEIN
16. Name
17. Code
18. Name
Count (PC1)
Types
22. TOTAL
23. TOTAL
21. TOTAL
$
ounces
PC1’S
Attach to your Michigan WT-100 AND AT-100 forms.

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