Form 373 (Schedule I) - Tobacco Products Sold To Indian Tribes, Tribal Members Or Other Retailers Located Within Indian Country

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Michigan Department of Treasury

373 (Rev. 6-06)

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Schedule I: Tobacco Products Sold to Indian Tribes, Tribal

Members or Other Retailers Located Within Indian Country*

NOTICE to Wholesalers, Unclassified Acquirers, Secondary Wholesalers, and Vending Machine Operators: Four copies of this

schedule must be completed for each sale of cigarettes and/or other tobacco products to Indian communities. The original must be

filed with your tobacco products tax return.

PART 2: BUYER

PART 1 : SELLER

Account No. (FE, TR or ME)

Licensee Name and Address

Purchaser Name and Address

PART 3: SALE INFORMATION

Total Number of Cigarettes Sold (NOTE: Enter number of individual cigarettes sold,

Date of Sale

not packs, cartons or cases)

Seller's Invoice No.

Total Wholesale Price of Other Tobacco Products Sold

PART 4: CERTIFICATION

I certify under penalty of perjury that the above information is true and correct. By signing below, I certify that any cigarette packs sold to/or purchased

by an Indian tribe, tribal member or other retailer located within Indian Country* bears a Michigan Tribal Stamp and that the proper tobacco tax has

been charged and paid on both cigarettes and other tobacco products.

Signature of Licensee Representative

Date

Signature of Tribal Representative

Date

PART 5: DISTRIBUTION

An original and three copies of this schedule must be made. Distribute as follows:

Original to wholesaler for filing with cigarette tax return.

Copy to wholesaler for company records.

Copy to Indian community for records.

Copy for Indian community to be sent to: