Form 4357 - Other Tobacco Products Tax - Exemption Certificate
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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4357
P.O. BOX 3320, JEFFERSON CITY MO 65105-3320
OTHER TOBACCO PRODUCTS TAX
(REV. 02-2012)
EXEMPTION CERTIFICATE
SEE REVERSE SIDE FOR IN STRUCTIONS
ISSUED TO (SELLER)
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
NAME OF BUSINESS (BUYER)
OTHER TOBACCO PRODUCTS LICENSE #
BUSINESS STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
The above named business is a licensed Wholesaler of Other Tobacco Products in the state of Missouri within which your firm would deliver purchases of Other
Tobacco Products (as defined by Chapter 149 RSMo, other than cigarettes) to us and that any such purchases are to be resold in the normal course of our business.
I further certify that these Other Tobacco Products (as defined by Chapter 149 RSMo, other than cigarettes) purchased tax free, will upon receipt of or at the time of
sale, have the appropriate amount of tax paid by our company direct to the state of Missouri.
GENERAL DESCRIPTION OF PRODUCTS TO BE PURCHASED FROM THE SELLER
I swear or affirm that the information on this form is true and correct as to every material matter. 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.
AUTHORIZED SIGNATURE (OWNER, PARTNER OR CORPORATE OFFICER)
TITLE
DATE
__ __ /__ __ /__ __ __ __
MO 860-4357 (02-2012)
This publication is available upon request in alternative accessible format(s). TDD 1-800-735-2966
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISON
4357
P.O. BOX 3320, JEFFERSON CITY MO 65105-3320
OTHER TOBACCO PRODUCTS TAX
(REV. 02-2012)
EXEMPTION CERTIFICATE
SEE REVERSE SIDE FOR IN STRUCTIONS
ISSUED TO (SELLER)
ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
NAME OF BUSINESS (BUYER)
OTHER TOBACCO PRODUCTS LICENSE #
BUSINESS STREET ADDRESS
CITY
STATE
ZIP CODE
__ __ __ __ __
The above named business is a licensed Wholesaler of Other Tobacco Products in the state of Missouri within which your firm would deliver purchases of Other
Tobacco Products (as defined by Chapter 149 RSMo, other than cigarettes) to us and that any such purchases are to be resold in the normal course of our business.
I further certify that these Other Tobacco Products (as defined by Chapter 149 RSMo, other than cigarettes) purchased tax free, will upon receipt of or at the time of
sale, have the appropriate amount of tax paid by our company direct to the state of Missouri.
GENERAL DESCRIPTION OF PRODUCTS TO BE PURCHASED FROM THE SELLER
I swear or affirm that the information on this form is true and correct as to every material matter. 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.
AUTHORIZED SIGNATURE (OWNER, PARTNER OR CORPORATE OFFICER)
TITLE
DATE
__ __ /__ __ /__ __ __ __
This publication is available upon request in alternative accessible format(s). TDD 1-800-735-2966
MO 860-4357 (02-2012)
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