Form 4343 - Other Tobacco Products Receipts Schedule Retailer Purchases From Unlicensed Out-Of-State Suppliers

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MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION

MONTH

YEAR

FORM

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

4343

OTHER TOBACCO PRODUCTS RECEIPTS SCHEDULE

RETAILER PURCHASES FROM UNLICENSED OUT-OF-STATE SUPPLIERS

(REV. 02‑2012)

COMPANY

LICENSE NO.

ADDRESS

CITY

STATE

ZIP CODE

___ ___ ___ ___ ___

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:

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MANUFACTURER’S INVOICE PRICE

INVOICE DATE

INVOICE NUMBER

PURCHASED FROM

ADDRESS (CITY, STATE, ZIP)

(BEFORE DISCOUNTS AND/OR DEALS)

_ _ / _ _ / _ _ _ _