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Form 4254 - C-103 Schedule Of Out-Of-State Cigarette Shipments (Michigan Based Licensees Exports Only)

Michigan Department of Treasury

4254 (04-10)

C-103: Schedule of Out-of-State Cigarette Shipments (Michigan Based Licensees Exports Only)

Important: Read the instructions on Page 2 before completing this schedule.

1. Name

2. Account Number (FEIN, TR or ME Number)

3. Michigan License Number

4. Reporting Period (MM/CCYY)

SCHEDULE TYPE:

CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.

C-103a: Schedule of Stamped Cigarettes for sale or transfer in the state of _______________________________________

C-103b: Schedule of Unstamped Cigarette shipments to the state of ____________________________________________

Non-Participating Manufacturer Product

19. Total

Sold to Information

Address of Purchaser

Manufacturer

Brand

14.Pack

5. Date

6. Invoice

7. Invoice

8. Branch

Cigarettes per

Size

Shipped

Date

Number

Code

9. FEIN

10. Name

11.Type

12. City

13.State

15. FEIN

16. Name

17.Code

18. Name

Entry

20. TOTAL

Attach to your Michigan WC-100 or AC-100 Forms.

Form 4254 - C-103 Schedule Of Out-Of-State Cigarette Shipments (Michigan Based Licensees Exports Only)