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Michigan Department of Treasury

AT-100

4245 (Rev. 01-13)

Michigan Unclassified Acquirers Other Tobacco Product (OTP) Tax Return

No Tax Due

This return is issued under authority of P.A. 327 of 1993 as amended. This form is to be

filed by all Unclassified Acquirers of Other Tobacco Products. Filing is mandatory. This

Check here if you discontinued/sold your business

return must be filed with payment on or before the 20th day of the month following the

close of the reporting period. See bottom of the return for mailing instructions.

Date (MM/DD/YY):

Company Name and Mailing Address

Check here if this is a corrected or amended return

Method of Inventory Reporting:

Physical

Book

Other (enter type):

Report Period (MM/CCYY)

Account Number (FEIN, TR or ME Number)

License Number

PART 1: OTHER TOBACCO PRODUCTS (OTP) RECEIPTS AND DISBURSEMENTS

1. OTP Purchases (receipts) (from T-101a and T-101c, total) ..................................................................................................... 1. $

2. Credits (from T-102a, Line 20, total) ........................................................................................................................................ 2. $

3. Tax-Unpaid OTP Sales to licensed Wholesalers (from T-108a, total)...................................................................................... 3. $

4. Tax-Unpaid OTP sold to Michigan Tribes (from T115a, total) .................................................................................................. 4. $

5. Total exemptions (add Lines 2, 3 and 4) .................................................................................................................................. 5. $

6. Taxable OTP sales in Michigan (from T-108b and T-115b, total) ............................................................................................. 6. $

PART 2: COMPUTATION OF AMOUNT DUE

7. Taxable OTP sales in Michigan (Enter amount from Line 6) ................................................................................................... 7. $

8. Tax Paid Credits of OTP only (from T-102b and T-103) ........................................................................................................... 8. $

9. Premium Cigars sold (wholesale price of all taxable premium cigars reported) ...................................................................... 9. $

10. Adjusted Taxable OTP Sales in Michigan (Subtract the sum of Line 8 and 9 from Line 7) ................................................... 10. $

11. Compute OTP Tax (Line 10 x $0.32) ..................................................................................................................................... 11. $

12. Number of Premium Cigars Sold (stick count) ...................................................................................................................... 12. $

13. Tax Paid Credits of Premium Cigars (from T-102b and T-103) (stick count) ......................................................................... 13. $

14. Compute Tax on Premium Cigars (Subtract Line 13 from Line 12 x $0.50) .......................................................................... 14. $

15. Total Tax Owed before Discount (Add amounts from Line 11 and Line 14) ........................................................................... 15. $

16. Compute 1% Tax Collection Allowance (Line 15 x $0.01) ..................................................................................................... 16. $

17. TOTAL NET TAX DUE (Line 15 minus Line 16) .................................................................................................................... 17. $

18. REFUND DUE (If Line 17 is less than zero enter here; if not, continue to Line 19) .............................................................. 18. $

19. Compute PENALTY (See instructions on calculating this amount) ....................................................................................... 19. $

20. Compute INTEREST (See instructions on calculating this amount) ...................................................................................... 20. $

21. TOTAL TAX, PENALTY, and INTEREST DUE (Add Lines 17, 19 and 20) ............................................................................ 21. $

This return must be filed with payment on or before the 20th day of the month following the close of the reporting period. See

instructions for more information.

CERTIFICATION

I certify under penalty of perjury that this return and attachments are true and complete to the best of my knowledge.

I authorize Treasury to discuss my return and attachments with my preparer.

Do not discuss my return with my preparer.

Authorized Signature

Printed Name

Telephone Number

Title

Date

Mailing Instructions:

Make checks payable to “State of Michigan.” Write the words “Tobacco Products Tax” and your account number on the front of your

check and mail to: Michigan Department of Treasury, P.O. Box 77628, Detroit, MI 48277-0628. If you have questions, please call

the Special Taxes Division at (517) 636-4630. Questions can also be emailed to treas_tobaccotaxes@michigan.gov. Deaf, hearing or

speech impaired persons call (517) 636-4999 (TTY).

Form At-100 - Michigan Unclassified Acquirers Other Tobacco Product (Otp) Tax Return

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