R-5604c-L - Report Form Of Cigarettes Made By Nonparticipating Manufacturers Imported Into Louisiana

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State of Louisiana

R-5604C-L (11/02)

Due date: This report is due

Department of Revenue

with the monthly tax return

during which the cigarettes of

Report of Cigarettes Made by Nonparticipating Manufacturers Imported into Louisiana

“roll-your-own” were imported.

License number

Name of licensee

FEIN or Social Security Number

Reporting month/year

Contact person

Telephone number

Instructions: The information on this report is required to comply with the Master Settlement Agreement (“Agreement”) entered into between certain tobacco manufacturers (“Participating Manufacturers”) and the State of

Louisiana. As part of the Agreement, information about cigarettes and loose-leaf tobacco suitable for making cigarettes (“roll-your-own”), made by manufacturers who did not sign the Agreement (“Non-Participating

Manufacturers”) must be compiled by the State. A list of Participating Manufacturers (PM) as of September 5, 2002 appears at the bottom of this form. You will be notified of any future additional PMs. If you purchase

cigarettes and/or roll-your-own tobacco from a manufacturer, either directly or through a distributor, which is not a participating manufacturer, complete this form and attach it to your monthly Cigarette and Tobacco Products

Excise Tax Return, Form R-5604, and forward a copy of form 5604-C to the Department of Justice, P.O. Box 94095, Baton Rouge, LA, 70804. Report only cigarettes and “roll-your-own” made by manufacturers not listed

below. If you did not purchase cigarettes or “roll-your-own” from manufacturers not listed below, this report must be filed indicating such.

Non-participating manufacturer name,

Invoice

Product brand name

Number of cigarettes sold

Did you affix a

If no, was it

Ounces of roll-

Name and address of the person(s) from

address, city, state,ZIP

number

within state