Form 5467 - State Cigarette Pact Act Pa-1 Report For Missouri
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Missouri Department of Revenue
5467
State Cigarette PACT Act PA-1 Report for Missouri
Business Name (Please Print)
Reporting Period (MM/YYYY)
Missouri Tax Identification Number
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Location Address
City
State or Province
Zip or Postal Code
Country or Territory
Federal Employer Identification Number (FEIN)
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Mailing Address
City
State or Province
Zip or Postal Code
Country or Territory
E-mail Address
Total Cigarettes*
Brand Family*
Invoice Date
Invoice Number
Customer Name*
Address*
Sales Price ($)**
(no. of sticks)
Total
Delivery Service Name*
Address*
Phone Number*
(___ ___ ___)___ ___ ___-___ ___ ___ ___
(___ ___ ___)___ ___ ___-___ ___ ___ ___
*Required by Prevent All Cigarette Trafficking Act
** Delivery sellers only
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature of Responsible Party
Printed Name of Responsible Party
Phone Number
(___ ___ ___)___ ___ ___-___ ___ ___ ___
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Title
E-mail Address
Date (MM/DD/YYYY
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Form 5467 (Revised 06-2013)
Mail to:
Phone: (573) 751-7163
Taxation Division
Visit dor.mo.gov/business/tobacco/ for additional information.
P.O. Box 811
Fax: (573) 522-1720
Jefferson City, MO 65105-0811
E-mail: excise@dor.mo.gov
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Parent category: Financial