Form R-5612 Pm - Participating Manufacturer'S Product - Schedule Of Cigarettes And Roll-Your-Own Sold Outside Louisiana - Non-Louisiana Sales

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R-5612 PM (11/13)

This schedule is due with the monthly tax return during which

Participating Manufacturer’s Product

the cigarettes or “roll-your-own” were reported.

Filing Period

Schedule of Cigarettes and

Contact Person

Roll-Your-Own Sold Outside Louisiana

NON-LOUISIANA SALES

Telephone Number

FEIN

Account Number

Name

Address

Instructions are on the reverse side and are available on the Louisiana Department of Revenue’s website under Forms. The information on this schedule is required to comply with Louisiana laws relating to the Master Settlement Agreement (“MSA”). You must file

this schedule even if you report zero amounts. Complete this schedule and attach the original to your monthly Tobacco Tax Return (Form R-5604), and forward a copy of this schedule, along with a computer printout of the brands and quantities of all sales of PM

cigarettes and roll-your-own to a jurisdiction other than Louisiana that occurred in the calendar month being reported, to the Department of Justice, Tobacco Section, P.O. Box 94005, Baton Rouge, LA 70804-9005.

Tax Value of Stamps

Number of

Stamp Affixed

Vendor Purchased From

Manufacturer or First Importer

Ounces of

Dollar Amount of

Product Country

Product Brand Name

Placed

State

Sticks of

Roll-Your-Own

of Origin

Yes

No*

Name

City, State

Name

City, State

on Cigarettes

Cigarettes

.00

Subtotal (if additional

.00

sheet needed)

Total

.00

*If “No” was indicated in Column D above, please provide an explanation on a separate sheet to detail the reason why no tax stamp was affixed to the product.

I swear, under penalty of perjury, that the above information is true and correct. By signing below, I acknowledge that I am the individual who prepared this form and have the authorization to submit such on behalf of the aforementioned entity.

Signature of Preparer

Print Name of Preparer

Title of Preparer

Date

(mm/dd/yyyy)