Form 4426-25 - Out-Of-State Missouri Cigarette Wholesaler Monthly Cigarette Tax Report Page 2

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FOR 25s ONLY
SCHEDULE B — STAMPED CIGARETTES RETURNED TO MANUFACTURER
NUMBER OF PACKAGES OF STAMPED
CIGARETTES RETURNED TO MANUFACTURER
SHIPMENT
INVOICE NUMBER(S)
NAME OF COMMON CARRIER
NAME OF MANUFACTURER
DATE
OF RETURNED CIGARETTES
STATE/JACKSON
STATE/ST. LOUIS
STATE ONLY
COUNTY
COUNTY
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
ENTER TOTALS ON FORM 4426-25, LINE 8
SCHEDULE B-1 — STAMPED CIGARETTES PURCHASED FROM ANOTHER LICENSED WHOLESALER
STATE/
STAMPED/
INVOICE NUMBER(S)
NAME OF WHOLESALER
INVOICE DATE(S)
STATE ONLY
JACKSON COUNTY
ST. LOUIS COUNTY
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
ENTER TOTALS ON FORM 4426-25, LINE 3
FORM 4426-25 (02-2012)

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