Form 304 - Cigarette Tax Stamp Record - Schedule C

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Form
Missouri Department of Revenue
304
Cigarette Tax Stamp Record-Schedule C
Wholesaler
Month ___ ___ Year ___ ___ ___ ___
License Number
Select the type of packs you will report on this schedule - One type per schedule
r
r
Twenty Packs
Twenty-five Packs
Complete each section and transfer the totals to Form 265 or Form 4426
Stamps Purchased - List the number of each type of stamp purchased during the month
Date
Invoice
(B) State
(D) State &
(C) State &
(E) Other States*
Number
Only
Jackson County
St Louis County
(MM/DD/YYYY)
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
Totals
(Also enter on Form 265 or
0
0
0
0
Form 4426)
Stamps Received for Credit - List the number of stamps received for credit on stamped cigarettes returned to manufacturer and
returned carton flaps or damaged decals
Date
Invoice
(B) State
(C) State &
(D) State &
(E) Other States*
Number
Only
St Louis County
Jackson County
(MM/DD/YYYY)
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
Totals
(Also enter on Form 265 or
0
0
0
0
Form 4426)
Stamps Used (Affixed) - On the last business day of the month, enter the total decals used during the month for each type
Last Business Date (MM/DD/YYYY):
__ __ / __ __ / __ __ __ __
(D) State &
(C) State &
(B) State
(E) Other States*
Jackson County
St Louis County
Only
Totals
(Also enter on Form 265 or
Form 4426)
*
Only in-state wholesalers are required to complete the column titled “Other States”.
Form 304 (Revised 06-2013)
Mail to: Taxation Division
Phone: (573) 751-7163
P.O. Box 811
TDD: (800) 735-2966
Visit dor.mo.gov/business/tobacco/
Jefferson City, MO 65105-0811
Fax: (573) 522-1720
for additional information.
E-mail: excise@dor.mo.gov

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