Form 4253 - C-115 Schedule Of Cigarettes Sold To Michigan Tribes

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Michigan Department of Treasury
4253 (04-10)
C-115: Schedule of Cigarettes Sold to Michigan Tribes
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-115a: Schedule of Tax-Unpaid Cigarettes Sold to Michigan Tribes
C-115b: Schedule of Tax-Paid Cigarettes Sold to Michigan Tribes
Non-Participating Manufacturer Product
19. Total
Tribe Information
Address of Purchaser
Manufacturer
Brand
14.Pack
5. Date
6. Invoice
7. Invoice
8. Branch
Cigarettes per
Size
17.
Shipped
Date
Number
Code
13. State
9. FEIN
10. Name
11.
12. City
15. FEIN
16. Name
18. Name
entry
Code
20. TOTAL
Attach to your Michigan WC-100 or AC-100 Forms.

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