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MISSOURI DEPARTMENT OF REVENUE
POSTMARK DATE
FORM
TAXATION DIVISION
5067
P.O. BOX 811
JEFFERSON CITY, MO 65105-0811
(REV. 03-2012)
(573) 751-7163
TDD (800) 735-2966
CONSUMER PAYMENT VOUCHER — CIGARETTE/OTHER TOBACCO PRODUCTS (OTP)
CONSUMER’S NAME
MONTH/YEAR
___ ___ / ___ ___ ___ ___
STREET ADDRESS
FEIN/SOCIAL SECURITY NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
PO BOX
CITY
STATE
ZIP
__ __ __ __ __
TELEPHONE NUMBER
E-MAIL ADDRESS
FAX NUMBER
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
(__ __ __) __ __ __ - __ __ __ __
PART 1 — CIGARETTE PURCHASES
(5)
(1)
(3)
(6)
(2)
(4)
Number of
Date
Internet Address and/or
Number of Cartons
Supplier’s Name
Brand of Cigarette
Cigarettes
Purchased
Catalog Sales Address
Purchased
per Pack
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
(7) TOTAL:
0
PART 2 — OTHER TOBACCO PRODUCTS (OTP) PURCHASES
(12)
(8)
(10)
(11)
(9)
Total Purchase Price
Date
Internet Address and/or
Type of Other Tobacco Product(s)
Supplier’s Name
(before discounts
Purchased
Catalog Sales Address
Purchased
and/or deals)
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
0
(13) TOTAL:
PART 3 — TAX CALCULATIONS
14.
TOTAL CARTONS OF CIGARETTES (Total from Line 7) .......................................................................................................................
15.
CIGARETTE TAX (Multiply Line 14 by Appropriate Tax Rate — see instructions) ..................................................................................
16.
TOTAL VALUE OF OTHER TOBACCO PRODUCTS (Total from Line 13) .............................................................................................
17.
OTHER TOBACCO PRODUCTS TAX (Multiply Line 16 by 10%) ............................................................................................................
18.
TOTAL TAX (Add Lines 15 and 17) ..........................................................................................................................................................
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.
SIGNATURE
I declare under the penalties of perjury that this return including any accompanying schedules and statements has been examined by me and to the best of my knowledge
and belief is a true, correct, and complete return made in good faith for the taxable period stated, pursuant to existing laws requiring the filing of this return.
PRINT NAME
AUTHORIZED SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
DOR-5067 (03-2012)