Form 4405 - Cigarette Decal Purchase Order Form

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DOR USE ONLY
FORM
MISSOURI DEPARTMENT OF REVENUE
DLN NUMBER _______________________________
TAXATION DIVISION
4405
P.O. BOX 811
INVOICE DATE _______________________________
JEFFERSON CITY, MISSOURI 65105-0811
PAYMENT DUE ON
CIGARETTE DECAL PURCHASE ORDER FORM
(REV. 02-2012)
CREDIT PURCHASES $ ______________________________
WHOLESALER
LICENSE NUMBER
STREET
CITY, STATE, ZIP CODE
E-MAIL
TELEPHONE NUMBER
FAX NUMBER
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
SHIPPING METHOD (WHOLESALER MUST PAY)
PAYMENT TERMS FOR DECALS
PLEASE PROVIDE ACCOUNT NUMBER
UPS
____________________________________________________________
UPS NEXT DAY AIR
____________________________________________________________
CASH
FEDERAL EXPRESS PRIORITY OVERNIGHT
____________________________________________________________
CREDIT
FEDERAL EXPRESS STANDARD OVERNIGHT
____________________________________________________________
DHL
____________________________________________________________
ON-LINE
PICK-UP
____________________________________________________________
OTHER (SHIPPER NOT LISTED ABOVE)
____________________________________________________________
NAME ___________________________________________________________________________________________________________________
COLUMN D
COLUMN E
COLUMN F
COLUMN G
COLUMN A
COLUMN B
COLUMN C
NUMBER
STATE COST
JACKSON COUNTY
ST. LOUIS COUNTY
MISSOURI STATE
JACKSON COUNTY
ST. LOUIS COUNTY
OF ROLLS
FOR DECALS
COST FOR DECALS
COST FOR DECALS
COST LESS
COST LESS
COST
ORDERED—
(COLUMN A TIMES
(COLUMN B TIMES
(COLUMN C TIMES
APPLICABLE
APPLICABLE
(NO DISCOUNT
MUST BE FULL
NUMBER OF ROLLS
NUMBER OF ROLLS IN
NUMBER OF ROLLS IN
DISCOUNT*
DISCOUNT*
ALLOWED)
DECAL DESCRIPTION
ROLLS
IN COLUMN D)
COLUMN D)
COLUMN D)
20 PACKS OF CIGARETTES
STATE STAMP — 4,000
$ 659.60
$
$
STATE STAMP — 30,000
$4,947.00
$
$
STATE/JACKSON COUNTY
$ 659.60
$ 196.00
$
$
STAMP — 4,000
STATE/JACKSON COUNTY
$4,947.00
$1,470.00
$
$
STAMP — 30,000
STATE/ST. LOUIS COUNTY
$ 659.60
$ 200.00
$
$
STAMP — 4,000
STATE/ST. LOUIS COUNTY
$4,947.00
$1,500.00
$
$
STAMP — 30,000
25 PACKS OF CIGARETTES
STATE STAMP — 4,000
$ 824.50
$
STATE/JACKSON COUNTY
$ 824.50
$ 245.00
$
$
STAMP — 4,000
STATE/ST. LOUIS COUNTY
$
$ 824.50
$ 250.00
$
STAMP — 4,000
0
0
0
$
$
$
á
COLUMN TOTALS
(COLUMN E)
(COLUMN F)
(COLUMN G)
1. JACKSON COUNTY SUBTOTAL DUE (COLUMN F) . ......... $
7. STATE SUBTOTAL DUE (COLUMN E) ............................... $
2. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) ...... $
8. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) ...... $
3. TOTAL DUE JACKSON COUNTY . ...................................... $
9. TOTAL DUE STATE ............................................................. $
1 0. LESS PAYMENT RECEIVED WITH PURCHASE ORDER . . $
4. SUBTOTAL DUE ST. LOUIS COUNTY (COLUMN G) . ........ $
5. LESS CREDIT AFFIDAVITS (FROM BACK OF FORM) ...... $
6. TOTAL DUE ST. LOUIS COUNTY . ...................................... $
TOTAL AMOUNT DUE ON STATE DECALS**
$
TOTAL AMOUNT DUE ON COUNTY DECALS **
$
(TOTAL FROM LINE 9 MINUS LINE 10)
(TOTAL OF LINES 3 AND 6 — MUST BE PAID AT TIME OF PURCHASE)
(CREDIT PURCHASES MUST BE PAID BY 15TH OF NEXT MONTH)
COUNTY CHECK NO.
STATE CHECK NO.
*IF DISCOUNT IS DISALLOWED, COST WILL BE ADJUSTED BY ADDING 3% TO STATE COST AND 2% TO JACKSON COUNTY COST
**SEPARATE CHECKS MUST BE SUBMITTED FOR STATE AND COUNTY
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit
or abatement if I employ such aliens.
SIGNATURE OF PERSON COMPLETING DECAL ORDER FORM
PRINT NAME
DATE
__ __ / __ __ / __ __ __ __
SEND TO: TAXATION DIVISION, EXCISE TAX, P.O. BOX 811, JEFFERSON CITY, MISSOURI 65105-0811. If you have questions or need assistance in completing this form, please call
(573) 751-7163 or email excise@dor.mo.gov. You may also obtain this form from the Department’s web site at: TDD (800) 735-2966
FORM 4405 (02-2012)

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