Form 4916 - Licensee'S Monthly Report Of Cigarettes And Roll-Your-Own Tobacco Page 2

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FORM 4916 - LICENSEE’S MONTHLY REPORT OF CIGARETTES AND ROLL-YOUR-OWN TOBACCO
BUSINESS NAME _______________________________________ LICENSE NUMBER _______________________________
FOR THE MONTH OF ________________ YEAR ________________
A
B
C
D
E
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
and Address of the Manufacturer
From Whom Each Brand was Purchased
Stamped for Sale in Missouri
on Which Tobacco Tax was Paid
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
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
Name
Street Address
Name
Street Address
City
State
City
State
__ __ __ __ __ __ __ __
Sticks
Ounces
_________________
Zip
Country
Zip
Country
FORM 4916 (02-2012)
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