Form 4255 - T-115 - Schedule Of Other Tobacco Products Sold To Michigan Tribes - 2010

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Michigan Department of Treasury
4255 (04-10)
T-115: Schedule of Other Tobacco Products Sold to Michigan Tribes
Important: Read the instructions on Page 2 before completing this schedule.
1. Name
2. Account Number (FEIN, TR or ME Number)
3. Michigan License Number
4. Reporting Period (MM/CCYY)
SCHEDULE TYPE
CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.
T-115a: Schedule of Tax-Unpaid Other Tobacco Products Sold to Michigan Tribes (must be authorized by the State of Michigan)
T-115b: Schedule of Tax-Paid Other Tobacco Products Sold to Michigan Tribes
NPM Roll-Your-Own (RYO) Tobacco Products
19. Total
Tribe Information
Address of Purchaser
Manufacturer
Brand
5. Date
6. Invoice
7. Invoice
8. Branch
14. Wholesale
Ounces per
11.
Shipped
Date
Number
Code
Price
9. FEIN
10. Name
12. City
13. State
15. FEIN
16. Name
17. Code
18. Name
Entry
21. TOTAL
20. TOTAL
$
ounces
Attach to your Michigan WT-100 and AT-100 Forms.

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Parent category: Financial
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