Form R-5612 PM Participating Manufacturer's Product - Schedule of Cigarettes and Roll-Your-Own Sold Outside Louisiana - Non-louisiana Sales (Pm) - Louisiana

Form R-5612 PM or the "Participating Manufacturer's Product - Schedule Of Cigarettes And Roll-your-own Sold Outside Louisiana - Non-louisiana Sales (pm)" is a form issued by the Louisiana Department of Revenue.

The form was last revised in November 1, 2013 and is available for digital filing. Download an up-to-date fillable Form R-5612 PM in PDF-format down below or look it up on the Louisiana Department of Revenue Forms website.

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R-5612 PM (11/13)
PM
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.
A
B
C
D
E
F
G
H
I
J
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
Roll-Your-Own
of Origin
Yes
No*
Name
City, State
Name
City, State
on Cigarettes
Cigarettes
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
Subtotal (if additional
.00
.00
sheet needed)
Total
.00
.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)
R-5612 PM (11/13)
PM
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.
A
B
C
D
E
F
G
H
I
J
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
Roll-Your-Own
of Origin
Yes
No*
Name
City, State
Name
City, State
on Cigarettes
Cigarettes
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
Subtotal (if additional
.00
.00
sheet needed)
Total
.00
.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)
R-5612 PM(i) (11/13)
General Information
The information on this schedule is required to comply with Louisiana laws relating to the Master Settlement Agreement (“MSA”).
Under Louisiana law (LSA-R.S. 13:5061 et seq. and LSA-R.S. 13:5071 et seq.), information about cigarettes and loose-leaf tobacco
suitable for making cigarettes (“roll-your-own”) reported on the Tobacco Tax Return (Form R-5604) must be itemized on this schedule.
Separate schedules must be completed for Participating Manufacturers and Non-Participating Manufacturers. A current list of cigarette
and roll-your-own tobacco manufacturers, approved for sale in Louisiana, is maintained on the Louisiana Attorney General’s website
hhtp://ladoj.ag.state.la.us or www.ag.state.la.us, and may be viewed by clicking on the link entitled “Tobacco Unit” followed by the
“Approved Manufacturers and Brands” link. 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.
This schedule is to be completed for all cigarettes and Roll-Your-Own (RYO) products manufactured by a Participating Manufacturer (PM)
and were invoiced to a jurisdiction other than Louisiana, regardless of whether a tax stamp was affixed on the product. Please note that
only PM product actually sold during the calendar month for sale shall be included on this schedule. Product remaining in the dealer’s
inventory as of the end of the reporting month shall NOT be reported on this schedule. Provide an explanation if no tax stamp was affixed
on any product included in this schedule. This schedule shall be completed only by those Louisiana licensed wholesale dealers holding
a stamping agent designation that are either domiciled in Louisiana or have a warehouse or other place of business located in Louisiana
AND affix tax stamps in both Louisiana and other tax jurisdictions.
Definitions
For the purposes of this schedule:
“Importer”
means any person in the United States to whom non-tax paid cigarettes manufactured in a foreign country
are shipped or consigned, any person who removes cigarettes for sale or consumption in the United
States from a customs-bonded manufacturing warehouse, and any person who smuggles or otherwise
unlawfully brings cigarettes into the United States.
“Inventory”
means the cigarettes, whether stamped or unstamped, and RYO acquired, possessed, or located on hand
in the warehouse of the wholesale dealer as of the last day of the month for which the report or schedule is
being completed and does not include cigarettes or RYO purchased or invoiced during the month reported.
“Invoiced”
means an itemized bill for goods SOLD per month, containing individual prices, the total charge, and the
terms of sale.
“Product Country of Origin”
means the country of origin listed on the packaging of the cigarettes or RYO being reported.
“Purchase”
means the total amount of cigarettes acquired per month in any manner, for any consideration and includes
transporting or receiving product in connection with a purchase.
“Sale or sell”
means any transfer, exchange or barter in any manner or by any means for any consideration. The term
includes distributing or shipping product in connection with a sale. References to a sale “in” or “into” a
state refer to the state of the destination point of the product in the sale, without regard to where title was
transferred. References to sale “from” a state refer to the sale of cigarettes that are located in that state to
the destination in question without regard to where title was transferred.
“Manufacturer”
means an entity that directly, and not exclusively through any affiliate:
(a) Manufacturers cigarettes anywhere that the manufacturer intends to be sold in the United States,
including cigarettes intended to be sold in the US through an importer, except if the importer is an
original PM as defined in the MSA.
(b) Is the first purchaser anywhere for resale in the United States of cigarettes manufactured anywhere
that the manufacturer does not intend to be sold in the United States.
(c) Becomes a successor of an entity described in (a) or (b). The term does not include an affiliate of a
manufacturer unless such affiliate itself falls within any of (a), (b), or (c).
Instructions
For each product invoiced during the calendar month:
Column A – Enter the brand name of the cigarette or RYO.
Column B – If cigarettes, enter the value of the stamps placed on the packages of cigarettes.
Column C – Indicate the state in or into which the product listed in Column A was invoiced.
Column D – If cigarettes, indicate if a tax stamp was affixed. If no tax stamp was affixed, please provide an explanation on a
separate sheet.
Column E – Enter the number of cigarette sticks for each brand listed in Column A.
Column F – Enter the number of ounces of RYO for each brand listed in Column A.
Column G – Enter the dollar value of each brand of RYO listed in Column A.
Column H – Enter the name and address of the vendor from whom the product in Column A was purchased.
Column I – Provide the name and address of the product manufacturer or the first importer of the product listed in Column A.
Column J – Provide the country of origin of each product listed in Column A.
If more than one sheet is needed to report the product invoiced within the reporting month, subtotal each sheet, and enter a total on the
final page of this schedule

Download Form R-5612 PM Participating Manufacturer's Product - Schedule of Cigarettes and Roll-Your-Own Sold Outside Louisiana - Non-louisiana Sales (Pm) - Louisiana

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