Form 4592 - Request For Cigarette Tax Records
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OFFICE USE ONLY
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4592
P.O. BOX 811, JEFFERSON CITY, MO 65105-0811
REQUEST FOR CIGARETTE TAX RECORDS
(REV. 03-2012)
The political subdivision of _____________________________________, Missouri, pursuant to the provisions of Section 32.057
and Chapter 149, RSMo, formally requests information pertaining to the administration, collection, and enforcement of its
cigarette tax.
NOTE: This request does not have to be renewed each year. Submit a new form only if a change is being
requested regarding authorized individuals, mailing address, shipping method, or if you are requesting
cancellation of information.
INDICATE SHIPPING METHOD AND PROVIDE ACCOUNT NUMBER
REPORT FREQUENCY
DELIVERY SERVICE (CHECK ONE)
ACCOUNT NUMBER
CHECK ONE
DHL
Monthly
FEDERAL EXPRESS
Quarterly
NEXT DAY AIR
Semi-Annually
UPS
Annually
US POSTAL SERVICE
If checked, city must furnish prepaid/stamped envelopes.
OTHER
IMPORTANT: ATTACH A COPY OF YOUR CIGARETTE TAX ORDINANCE.
CANCELLATION REQUEST
We no longer wish to receive cigarette tax information.
AUTHORIZED INDIVIDUALS RECEIVING REPORTS
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
PRINT NAME
SIGNATURE OF AUTHORIZED INDIVIDUAL
DATE
_ _ / _ _ / _ _ _ _
MAILING ADDRESS FOR REPORTS
POLITICAL SUBDIVISION
PHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
STREET
CITY
STATE
ZIP CODE
___ ___ ___ ___ ___
As chief executive of this political subdivision, I authorize and hereby confirm that the individual(s) named above will receive informa-
tion on behalf of the political subdivision. We have reviewed and will comply with Chapter 149, RSMo and Section 32.057, RSMo,
pertaining to the strict confidentiality of all records of the Missouri Department of Revenue to which access has been granted.
PRINT NAME OF MAYOR/PRESIDING COMMISSIONER
SIGNATURE
TITLE
DATE
_ _ / _ _ / _ _ _ _
MAIL COMPLETED FORM TO TAXATION DIVISION, P.O. BOX 811, JEFFERSON CITY, MO 65105-0811.
If you have questions or need assistance in completing this form, please call (573) 751-7163 (TDD 1-800-735-2966) during the hours of 8:00 a.m. to
5:00 p.m., Monday through Friday or e-mail excise@dor.mo.gov. You may also access this form from the Department’s web site:
DOR-4592 (03-2012)
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