MT-203-W-T (11/10) Page 3 of 4
Transfers and wholesale sales of tobacco products outside of New York State
Schedule 4 — Transfers and wholesale sales of cigars and tobacco products (other than little cigars and snuff) outside of New York State
A
B
Name and address of business located
Cigars (other than little cigars)
Other tobacco products
outside of New York State to whom you
EIN of customer
No. of individual
transferred and/or sold product
cigars
Selling price
Pounds of tobacco
Selling price
A
B
C
19 Total transfers and wholesale sales from this Schedule 4
20 Total transfers and wholesale sales from additional attached sheet(s), if any
21 Total transfers and wholesale sales
(add lines 19 and 20; enter here and on
Form MT-203-W, line 5, columns A and B)
22 Total selling price from this Schedule 4
23 Total selling price from additional attached sheet(s), if any
24 Total selling price
(add lines 22 and 23)
(continued on page 4)