Form 4154 - Tobacco Products Tax Electronic Filing Application

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Michigan Department of Treasury
4154 (Rev. 03-12)
Tobacco Products Tax Electronic Filing Application
This form is issued under authority of P.A. 327 of 1993, as amended.
Company Name
Application Date
Mailing Address
City
State
ZIP Code
FEIN Number
Phone Number
Fax Number
Based on your average tax return filing size, choose your primary filing option. See page 2 for additional information.
Tobacco Tax Roles - Other Tobacco Products Only
Web Direct Fillable Forms
ASCII Flat File
(A completed Trading Partner Agreement (Form 3999) is required for all new applicants.)
RENEW
OTHER TOBACCO PRODUCTS
ONLY
Prepare Tax Returns/
Contact Telephone
Contact E-mail
Secondary
Contact Name
User ID
Inventory Adjuster
Number
Address
Wholesaler
RENEW
ADD
REMOVE
RENEW
ADD
REMOVE
RENEW
ADD
REMOVE
TOBACCO TAX ROLES - CIGARETTES ONLY
FILING OPTIONS (Select only one option) See Page 2 for instructions and additional information.
Web Direct Fillable Forms
ASCII Flat File
Select the required roles for you and/or your staff by placing and X in the appropriate box.
Wholesalers and
RENEW
You must include their name. See Page 2 for instructions and an example of completed form.
Unclassified
ONLY
Acquires Only
Contact Telephone
Secondary
Prepare Tax Returns/
Order
Receive
Contact E-mail
User ID
Contact Name
Number
Wholesaler
Inventory Adjuster
Stamps
Stamps
Address
RENEW
ADD
REMOVE
RENEW
ADD
REMOVE
RENEW
ADD
REMOVE
RENEW
ADD
REMOVE
INTERNET FTP SERVER DISCLAIMER: The system is for the use of authorized clients only. Individuals using the computer network system without
authorization, or in excess of their authorization, are subject to having all their activity on this computer network system monitored and recorded by
system personnel. To protect the computer network system from unauthorized use and to ensure the computer network systems is functioning
properly, system administrators will monitor this system. Anyone using this computer network system expressly consents to such monitoring and is
advised that if such monitoring reveals possible conduct of criminal activity, system personnel may provide the evidence of such activity to law
enforcement officers. Access is restricted to authorized users only. Unauthorized access is a violation of state, federal, civil and criminal laws.
AUTHORIZATION
Licensee identification number and password, when included as part of the report filed pursuant to this Agreement, shall constitute the signature of the
Licensee on the Report as if such Report were actually signed by the Licensee. Each party shall adopt as its signature an electronic identification
consisting of codes in each electronic transmission transmitted by such Party (the "Signature"). Each party agrees that any Signature of a Party affixed
to or contained in any transmitted electronic transmission shall be sufficient to verify the Party originated such electronic transmission. Neither Party
shall disclose to any unauthorized person the Signature of the other Party. Each Party agrees to maintain adequate back-up files to recreate electronic
transmission as required. Back-up files shall be subject to the terms of this Agreement to the same extent as the original data. Electronic
transmissions shall be retained for such periods as required by relevant Michigan statutes.
Authorized Signature
Title
Date

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