Form 4405 - Cigarette Decal Purchase Order Form Page 2
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2LIST INFORMATION BELOW FOR MANUFACTURER RETURN AFFIDAVITS. ATTACH ORIGINAL AFFIDAVITS TO ORDER FORM TO RECEIVE CREDIT.
INFORMATION ON PACKAGES OF 20 CIGARETTES
STATE COST (LESS 3% DISCOUNT)
TOTAL CREDIT ALLOWED FOR STATE DECALS
ENTER NO. OF PACKAGES
TOTAL NO. OF PACKAGES TIMES $0.1649 =
$ (ENTER ON LINE 1 BELOW)
STATE DECALS
JACKSON COUNTY COST (LESS 2% DISCOUNT)
TOTAL CREDIT ALLOWED FOR JACKSON COUNTY
ENTER NO. OF PACKAGES
JACKSON
TOTAL NO. OF PACKAGES TIMES $0.049 =
$ (ENTER ON LINE 3 BELOW)
COUNTY
ST. LOUIS COUNTY COST (NO DISCOUNT ALLOWED)
TOTAL CREDIT ALLOWED FOR ST. LOUIS COUNTY
ENTER NO. OF PACKAGES
ST. LOUIS
TOTAL NO. OF PACKAGES TIMES $0.05 =
$ (ENTER ON LINE 5 BELOW)
COUNTY
INFORMATION ON PACKAGES OF 25 CIGARETTES
STATE COST (LESS 3% DISCOUNT)
TOTAL CREDIT ALLOWED FOR STATE DECALS
ENTER NO. OF PACKAGES
TOTAL NO. OF PACKAGES TIMES $0.206125 =
$ (ENTER ON LINE 2 BELOW)
STATE DECALS
JACKSON COUNTY COST (LESS 2% DISCOUNT)
TOTAL CREDIT ALLOWED FOR JACKSON COUNTY
ENTER NO. OF PACKAGES
JACKSON
TOTAL NO. OF PACKAGES TIMES $0.06125 =
$ (ENTER ON LINE 4 BELOW)
COUNTY
ST. LOUIS COUNTY COST (NO DISCOUNT ALLOWED)
TOTAL CREDIT ALLOWED FOR ST. LOUIS COUNTY
ENTER NO. OF PACKAGES
ST. LOUIS
TOTAL NO. OF PACKAGES TIMES $0.0625 =
$ (ENTER ON LINE 6 BELOW)
COUNTY
1. STATE TOTAL FOR 20s . ........................................ $
5. ST. LOUIS COUNTY TOTAL FOR 20s . .................. $
2. STATE TOTAL FOR 25s . ........................................ $
6. ST. LOUIS COUNTY TOTAL FOR 25s . .................. $
TOTAL STATE CREDIT ALLOWED ...................... $
TOTAL ST. LOUIS COUNTY CREDIT ALLOWED $
(ENTER ON PAGE 1, LINE 8)
(ENTER ON PAGE 1, LINE 5)
3. JACKSON COUNTY TOTAL FOR 20s ................... $
4. JACKSON COUNTY TOTAL FOR 25s ................... $
TOTAL JACKSON COUNTY CREDIT ALLOWED $
(ENTER ON PAGE 1, LINE 2)
FOR DEPARTMENT OF REVENUE USE ONLY
20 CIGARETTES
TYPE ORDERED
CIGARETTE DECALS ORDERED
BEGINNING SERIAL NUMBER
ENDING SERIAL NUMBER
TOTAL NUMBER OF DECALS SHIPPED
ROLLS X 4,000
.17 DECALS
ROLLS X 30,000
ROLLS X 4,000
.22 STATE/
JACKSON CO.
ROLLS X 30,000
ROLLS X 4,000
.22 STATE/
ST. LOUIS
COUNTY
ROLLS X 30,000
25 CIGARETTES
TYPE ORDERED
CIGARETTE DECALS ORDERED
BEGINNING SERIAL NUMBER
ENDING SERIAL NUMBER
TOTAL NUMBER OF DECALS SHIPPED
.2125 DECALS
ROLLS X 4,000
.275 STATE/
ROLLS X 4,000
JACKSON CO.
.275 STATE/
ST. LOUIS
ROLLS X 4,000
COUNTY
DATE SHIPPED
TRACKING NUMBER
SHIPPING CLERK
__ __ / __ __ / __ __ __ __
SIGNATURE OF PERSON PICKING DECALS UP AT RECORD CENTER
DATE PICKED UP
__ __ / __ __ / __ __ __ __
FORM 4405 (02-2012)
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