Form 4916 - Licensee'S Monthly Report Of Cigarettes And Roll-Your-Own Tobacco

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FORM

MISSOURI DEPARTMENT OF REVENUE

4916

P.O. BOX 811, JEFFERSON CITY, MO 65105-0811

LICENSEE’S MONTHLY REPORT OF CIGARETTES

Print Form

(REV. 02-2012)

AND ROLL-YOUR-OWN TOBACCO

FOR THE MONTH OF _______________________________________________ YEAR ________________

Wholesalers on a deferred payment basis and retailers who purchase from unlicensed suppliers must file this report on or before the fifteenth (15th) day of the month. Wholesalers on a cash

basis must file this report on or before the twentieth (20th) day of the month. Wholesalers list all cigarettes stamped by your company for sale in Missouri and all ounces of roll-your-own

tobacco products sold in Missouri. Retailers list all roll-your-own tobacco products purchased from unlicensed suppliers for sale in Missouri. (ATTACH COPIES OF INVOICES FOR ANY

NON-PARTICIPATING MANUFACTURER’S BRANDS.) THIS REPORT MUST BE FILED, EVEN IF NO ACTIVITY OCCURRED DURING THE REPORTING PERIOD.

BUSINESS NAME

LICENSE NUMBER

___ ___ ___ ___

ADDRESS

CONTACT PERSON

CITY

STATE

ZIP

TELEPHONE NUMBER

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

___ ___ ___ ___ ___- ___ ___ ___ ___

Number of Cigarette (sticks)

Ounces of Roll-Your-Own Tobacco

For Each Brand, List the Complete Name

For Each Brand, List the Name and Address of the Person

Full Brand Name

Stamped for Sale in Missouri

on Which Tobacco Tax was Paid

and Address of the Manufacturer

From Whom Each Brand was Purchased

Name

Street Address

Name

Street Address

City

State

City

State

Sticks

Ounces

__ __ __ __ __ __ __ __

_________________

Zip

Country

Zip

Country

Name

Street Address

Name

Street Address

City

State

City

State

__ __ __ __ __ __ __ __

Sticks _________________

Ounces

Zip

Country

Zip

Country

Name

Street Address

Name

Street Address

City

State

City

State

Sticks

Ounces

__ __ __ __ __ __ __ __

_________________

Zip

Country

Zip

Country

If additional space is needed, continue on back or attach a list.

I SWEAR UNDER PENALTY OF PERJURY, THAT I HAVE KNOWLEDGE OF THE FACTS REPRESENTED IN THIS REPORT, THAT THEY ARE COMPLETE AND ACCURATE, THAT THE DOCUMENT IS PREPARED PURSUANT TO THE PUBLIC DUTY PRESCRIBED

BY MISSOURI LAW, AND THAT I HAVE THE AUTHORITY TO MAKE THESE REPRESENTATIONS ON BEHALF OF THE ABOVE-NAMED LICENSEE.

SIGNATURE

PRINT NAME

TITLE

DATE

___ ___ / ___ ___ / ___ ___ ___ ___

Mail report to: Missouri Department of Revenue, P.O. Box 811, Jefferson City, MO 65105-0811.

If you have questions or need assistance in completing this form, please call (573) 751-7163 or e-mail excise@dor.mo.gov.

You may also obtain this form from the Department’s web site at: https://dor.mo.gov/forms/index.php?category=14. TDD (800) 735-2966

FORM 4916 (02-2012)