Form 4241 - Tobacco Products Tax Payment/proposed Adjustments Coupon printable pdf download

Form 4241 - Tobacco Products Tax Payment/proposed Adjustments Coupon

Instructions: This form is to be used for payment of an electronically ﬁ led Tobacco Products tax

report or for payment of an adjustment to your report that was initiated by the Michigan Depart-

ment of Treasury. If you are paying on a proposed adjustment, include a copy of the letter to

which your payment applies. You must use a separate coupon for each payment, however you

may write one check. If you have any questions concerning this form please call the Special

Taxes Division at (517) 636-4630.

Detach here and mail in coupon only

Michigan Department of Treasury

4241 (7-09)

Tobacco Products Tax Payment/Proposed Adjustments Coupon

Issued under P.A. 327 of 1993, as amended.

CHECK BOX THAT APPLIES

Payment is for proposed adjustment for the ﬁ le period _________________________

(mm/yy)

Regular/amended Tobacco Products payment. Payment is for an original/amended electronically ﬁ led Tobacco

Products tax report for the ﬁ le period _________________

(mm/yy)

Account Number

Payment Enclosed

Business Name

Make checks payable to “State of Michigan” and mail with this coupon to:

Michigan Department of Treasury; P.O. Box 77628; Detroit, MI 48277-0628

Form 4241 - Tobacco Products Tax Payment/proposed Adjustments Coupon