Form 3669 (Schedule K) - Cigarettes And "Roll-Your-Own" (Ryo) Tobacco Products Acquired From Non-Participating Manufacturers Including Importers On Record (Npm'S)

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Michigan Department of Treasury
3669 (Rev. 7-03)
Schedule K: Cigarettes and "Roll-Your-Own" (RYO) Tobacco Products Acquired from Non-Participating
Manufacturers Including Importers on Record (NPM's)*
Issued under authority of P.A. 327 of 1993, as amended. Filing is mandatory. Schedule K must be filed even though no tobacco products were acquired from NPM's.
4
1. Name of Licensee
3. Contact Name
5. FEIN, TR or ME No.
4
2. Address (No., Street. City, State, ZIP)
4. Telephone Number
6. Return Period (Year/Month)
Read the instructions on page 2 before completing this schedule. File a separate schedule for each month you are reporting. Attach additional sheets if necessary.
PART 1 - CIGARETTES AND RYO TOBACCO ACQUIRED FROM NPM'S*
Tobacco products purchased/acquired must also be reported on Schedule A or F. Report each brand on a separate line.
7. Date on invoice
8. Invoice
9. Non-Participating Manufacturer
10. Brand Name.
11. Number of
12. Quantity of RYO Acquired/Transferred
for sale
Number for sale
Name and Address. Use full name - no abbreviations
Use full name. No
individual cigarettes
within the State
into Michigan
into Michigan
abbreviations.
Acquired/Transferred
Pounds
Ounces
Kilograms
within the state
PART 2 - RETURNS TO NPM'S OR TRANSFERS TO OTHER STATES*
Returns or Transfers out of Michigan must also be reported on Schedule C (R) or C (T). Use a separate line for each brand name.
13. Date on
14. Invoice
15. Non-Participating Manufacturer
16. Brand Name.
17. Number of
18. Quantity of RYO Transferred from Michigan
invoice of transfer
Number of
Name and Address. Use full name - no abbreviations
Use full name.
individual cigarettes
from Michigan
transfer from
No abbreviations.
Transferred from
Pounds
Ounces
Kilograms
Michigan
Michigan
* See definition of Non-Participating Manufacturer (NPM) on page 2 of this form.
Attach to your "Michigan Tobacco Products Tax Return" and mail to:
Michigan Department of Treasury
This form is for reporting purposes only. It is not used for the calculation of tax.
P.O. Box 77628
If you have questions, please call the Customer Contact Division, Tobacco Tax Unit at
(517) 636-4630. Deaf, hearing or speech impaired persons call (517) 636-4999 (TTY).
Detroit, MI 48277-0628

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