REVISED January 2018 1 OF 3 MONTANA DEPARTMENT OF JUSTICE Montana Licensed Wholesaler Reporting Form Please provide the following information with respect to all cigarettes, "roll-your-own" tobacco, and little cigars as defined in Mont. Code Ann. 247 16-11-402(4) stamped for sale or sold within Montana. A list of tobacco products that may be sold in Montana is located at: Tobacco Sales and Directory & Tobacco Settlement - Montana Department of Justice . If you do not file by the 20th day of the month, you will be fined $50 per day up to a maximum of $1,000 until the report is filed. You must file a report each month, whether or not you had any sales in that particular month. For the Month of , 20 Business Name and Address: Contact Person: Telephone: Fax: Email: NO Participating Manufacturer (PM) products were stamped or sold by wholesaler during this reporting month. NO Non-Participating Manufacturer (NPM) products were stamped or sold by wholesaler during this reporting month. PART 1: FOR Retailers Responsible for Payment of State Excise Taxes on Roll-Your-Own (RYO) the Retailer Purchased from Manufacturer RYO Brand Name RYO Manufacturer Name Ounces of RYO Name of Retailer Address of Retailer Invoice No. Attach copies of all invoices showing sales of RYO to retailers on which the retailer was responsible for paying the tax. (Maintain records for five (5) years per Mont. Code Ann. 247 16-11-507.) I hereby swear that the above-stated information is true and correct. Signature Date Return this completed form 15 days after the close of the reporting month to: B. Bessey, Compliance Montana Attorney General's Office of Consumer Protection Tobacco Enforcement Program P.O. Box 200151 Helena, MT 59620-0151 Fax: (406) 442-1894 Email: bbessey@mt.gov American LegalNet, Inc. www.FormsWorkFlow.com REVISED January 2018 2 OF 3 PART 2: Participating Manufacturers PM Brand Name Participating Manufacturer Name No. of Cigarettes Stamped or Sold Ounces of RYO Sold No. of Little Cigars Stamped or Sold I hereby swear that the above-stated information is true and correct. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com REVISED January 2018 3 OF 3 PART 3: Non-Participating Manufacturers NPM Brand Name Non-Participating Manufacturer Name No. of Cigarettes Stamped or Sold Ounces of RYO Sold No. of Little Cigars Stamped or Sold Invoice No. Attach copies of all purchase orders and retail sales invoices for all NPM products sold. (Maintain records for five (5) years per Mont. Code Ann. 247 16-11-507.) I hereby swear that the above-stated information is true and correct. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com