Form 4259 - T-101 Schedule Of Other Tobacco Product Purchases (Receipts)

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Michigan Department of Treasury
4259 (Rev. 01-13)
T-101: Schedule of Other Tobacco Product Purchases (Receipts)
Important: Read the instructions on Page 2 before completing this schedule.
1. Name
2. Account Number (FEIN, ME or TR Number)
3. Michigan License Number
4. Reporting Period (MM/CCYY)
SCHEDULE TYPES:
CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.
T-101a: Schedule of Tax-Unpaid Other Tobacco Product Purchases for Michigan (Michigan based licensees only)
T-101b: Schedule of Michigan Tax Paid Other Tobacco Product Purchases (Wholesalers only)
T-101c: Schedule of Returned Tax Paid Other Tobacco Product from Michigan customers
NPM Roll-Your-Won (RYO) Tobacco Products
20. Total
Tribe Information
Address of Purchaser
14.
Manufactuer
Brand
19. Total
5. Date
6. Invoice
7. Invoice
8. Branch
Premium
11. Type
Whole-
Ounces per
Shipped
Date
Number
Code
Cigar Stick
9. FEIN
10. Name
12. City
13. State
sale Price
15. FEIN
16. Name
17. Code
18. Name
Entry
Count (PC1)
22. TOTAL
23. TOTAL
21. TOTAL
$
ounces
PC1’S
Attach to your Michigan WT-100, AT-100, and ST-100 forms.

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