Form 5067 - Consumer Payment Voucher - Cigarette/other Tobacco Products (Otp)

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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:

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)

_ _ / _ _ / _ _ _ _

(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)