Form 4342 - Other Tobacco Products Monthly Report - Out-Of-State Wholesalers Selling Into Missouri

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DLN

MISSOURI DEPARTMENT OF REVENUE

TAXATION DIVISION

FORM

P.O. BOX 3320, JEFFERSON CITY, MO 65105-3320

4342

OTHER TOBACCO PRODUCTS

(REV. 10-2011)

MONTHLY REPORT — OUT-OF-STATE

WHOLESALERS SELLING INTO MISSOURI

DUE ON OR BEFORE THE 15TH OF EACH MONTH FOLLOWING THE REPORT MONTH

CHECK HERE IF

COMPANY

LICENSE NO.

MONTH/YEAR

AMENDED

___ ___ / ___ ___ ___ ___

REPORT

STREET ADDRESS

TELEPHONE

(__ __ __) __ __ __ - __ __ __ __

CITY

STATE

ZIP CODE

___ ___ ___ ___ ___

LIST ALL TOBACCO PRODUCTS DISTRIBUTED OR DELIVERED INTO MISSOURI

MANUFACTURER’S INVOICE PRICE

INVOICE DATE

INVOICE NUMBER

CONSIGNEE

ADDRESS

(BEFORE DISCOUNTS AND/OR DEALS)

_ _ / _ _ / _ _ _ _

1. Total manufacturer’s invoice price (All products distributed or delivered into Missouri) ........................

2. EXEMPTIONS:

2A. Product returned from Missouri retail customers (Complete

Schedule B on reverse side) ................................................... 2A

2B. Military sales (Complete Schedule D on reverse side) ........... 2B

2C. Sales to other Missouri licensed wholesalers

(Complete Schedule E on reverse side) ................................. 2C

TOTAL (Lines 2A, 2B and 2C) ...............................................................................................................

3. Taxable other tobacco products (Line 1 less Line 2) .............................................................................

4. Multiply Line 3 by 10% ...........................................................................................................................

5. Less 2% timely payment discount (Line 4 times 2%) (Forfeited if not timely remitted) ..........................

6. Total tax due (Line 4 less Line 5) ...........................................................................................................

7. Penalty (25% late penalty) (Line 6 times 25%) ......................................................................................

8. Total tax and penalty due (Line 6 plus Line 7) .......................................................................................

9. Interest (See Line 9 of Instructions) (Calculate using figure on Line 8) .................................................

10. Less credit (Attach letter of credit) .........................................................................................................

11. Less credit for product returned directly to manufacturer by retailer (Attach tax affidavit from

manufacturer and refund/credit memo to retailer ...................................................................................

12. TOTAL DUE (Line 8 plus Line 9, minus Line 10 and Line 11) ...............................................................

I do hereby certify under the penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and is a complete and full presentation of all

transactions from the best information available. I also 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

PRINT NAME

TITLE

DATE

__ __ / __ __ / __ __ __ __

REPORT MUST BE ACCOMPANIED BY FULL REMITTANCE OF TOTAL DUE (LINE 11)

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.

Make check payable to MISSOURI DEPARTMENT OF REVENUE, and mail to: Taxation Division, Excise Tax, P.O. Box 3320, Jefferson City, Missouri

65105-3320. If you have questions or need assistance in completing this form, please call (573) 751-5772 (TDD 1-800-735-2966) or e-mail excise@dor.mo.gov.

You may also access this form from the Department’s web site:

(10-2011)