Schedule A (Form 4795) - Tobacco Products - Other Than Cigarettes Retailer Export Sales

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DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4795
P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320
TOBACCO PRODUCTS —
OTHER THAN CIGARETTES
(REV. 03-2012)
RETAILER EXPORT SALES — SCHEDULE A
COMPANY
LICENSE NO.
MONTH/YEAR
___ ___ / ___ ___ ___ ___
If you have questions or need assistance in completing this form, please call (573) 751-5772 (TDD 1-800-735-2966) or e-mail excise@dor.mo.gov. You
may also access this form from the Department’s web site:
SALES MADE TO PERSONS OUTSIDE THE STATE OF MISSOURI — COMPLETE A SEPARATE SCHEDULE FOR
EACH STATE TO WHICH PRODUCT IS EXPORTED. PLEASE SUBMIT TWO (2) COPIES OF EACH STATE’S SCHEDULE.
YOUR
YOUR
SHIP TO ADDRESS
MANUFACTURER’S INVOICE PRICE
TO WHOM SOLD
INVOICE DATE
INVOICE NUMBER
(STREET, CITY, STATE, ZIP)
(BEFORE DISCOUNTS AND/OR DEALS)
$
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0
SCHEDULE TOTAL (Enter on Line 4A of Form 4341) .....................................................................................
$
DOR-4795 (03-2012)

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