Form 5067 - Consumer Payment Voucher - Cigarette/other Tobacco Products (Otp) Page 2
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1
2INSTRUCTIONS FOR COMPLETING CIGARETTE AND OTHER TOBACCO
PRODUCTS CONSUMER PAYMENT VOUCHER
If you have questions or need assistance in completing this form, please call (573) 751-7163, (573) 751-5772, or e-mail
excise@dor.mo.gov. You may also obtain this form from the Department’s web site at:
index.php?category=14. TDD (800) 735-2966
Cigarette — An item manufactured of tobacco or any substitute thereof, wrapped in paper or any substitute thereof,
weighing not to exceed three pounds per one thousand cigarettes and which is commonly classified, labeled or
advertised as a cigarette.
Other Tobacco Product — Any other consumable tobacco product that is not labeled or advertised as a cigarette. i.e.,
chewing tobacco (snuff), loose-leaf tobacco (roll-your-own), cigars, cigarette papers, cigarette tubes, blunt wraps, or
filtered tips.
PART 1 — CIGARETTE PURCHASES
Column 1: Enter the date of your cigarette purchase(s). List each purchase separately.
Column 2: Enter the name of the company from whom you purchased cigarettes.
Column 3: If your purchase was from an Internet retailer, enter their web address. If your purchase was made from a
catalog, enter their sales address.
Column 4: Enter the brands of cigarettes purchased.
Column 5: Enter the number of cigarettes per pack. Generally this will be 20 or 25.
Column 6: Enter the number of cartons purchased.
Line 7: Total of Column 6. If you made no cigarette purchases, enter $0.
PART 2 — OTHER TOBACCO PRODUCTS (OTP) PURCHASES
Column 8: Enter the date of your OTP purchase(s). List each purchase separately.
Column 9: Enter the name of the company from whom you purchased OTP.
Column 10: If your purchase was from an Internet retailer, enter their web address. If your purchase was made from a
catalog, enter their sales address.
Column 11: Enter the type of OTP purchased. Including: chewing tobacco (snuff), loose-leaf tobacco (roll-your-own),
cigars, cigarette papers, cigarette tubes, blunt wraps, filtered tips, or any other consumable tobacco product that is not a
cigarette.
Column 12: Enter the total paid for your OTP purchase. Do not reduce price entered by any discounts or rebates
offered by the seller.
Line 13: Total of Column 12. If you made no OTP purchases, enter $0.
PART 3 — TAX CALCULATION
Line 14: Enter amount from Line 7.
Line 15: Multiply Line 14 by the appropriate tax rate. Packs of 20 cigarettes are taxed at a rate of $.17 per pack or
$1.70 per carton. Packs of 25 cigarettes are taxed at a rate of $.2125 per pack or $2.125 per carton. Round to the
nearest whole dollar.
Line 16: Enter amount from Line 13.
Line 17: Multiply Line 16 by 10% (.10).
Line 18: Sum of Line 17 and Line 15.
DOR-5067 (03-2012)
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