Other Tobacco Product Distributors Excise Tax Return {OPT-M}

State Form 46853 (R5 / 7-16) OTP-M Form Other Tobacco Product Distributor's Excise Tax Return Reporting Month _______________ Year __________ Indiana Department of Revenue Amended No Activity This return must be postmarked on or before the 15th day of the month following the reporting month. Section A: Taxpayer Information Name (As It Appears on License) Physical Address/City/State/ZIP Mailing Address/City/State/ZIP Email Address Distributor License Number Federal Identification Number Indiana Taxpayer Identification Number Section B: Excise Tax Calculation (A) All OTP Except Moist Snuff (wholesale price) 1. 2. 3. 4. 5. 6. 7. 8. 9. Purchases (resident)/Shipments (nonresident) of Other Tobacco Products (Schedule OTP-M-S Transaction Type A). Other Tobacco Products Shipped Out of State (Schedule OTP-M-S Transaction Type B). Other Tobacco Products Returned to Manufacturer (Schedule OTP-M-S Transaction Type C). Other Tobacco Products Sold to Federal Government (Schedule OTP-M-S Transaction Type D). Tax Paid Purchases from Indiana Licensed Distributors (Schedule OTP-M-S Transaction Type E). Untaxed Sales to Indiana Licensed Distributors (Schedule OTP-M-S Transaction Type F). Total Deductions (add Lines 2 through 6). Duplicate Deduction Add-Back. Taxable Tobacco After Deductions (Line 1 minus Line 7 plus Line 8). (B) Moist Snuff (ounces) 10. Tax on Other Tobacco Products per Column (multiply Line 9A by 0.24; multiply Line 9B by 0.40). 11. Total Tax on Other Tobacco Products (Line 10A plus Line 10B). 12. Collection Allowance for Timely Payment (multiply Line 11 by 0.007). 13. Tax Due or Refund Claimed (Line 11 minus Line 12). 14. Penalty (10% of tax due or $5, whichever is greater, if filed late). 15. Interest. 16. Total Amount Due or Refund Claimed (add Lines 13 through 15). Additional Information -- Not Part of Tax Calculation. 17. Intrastate Sales (Schedule OTP-M-S Transaction Type G). I hereby certify, under penalty of perjury, that the information contained herein and on supporting documents, is true, correct, and complete to the best of my knowledge and belief. Signature of Taxpayer or Agent: _______________________________________________ Printed Name of Taxpayer or Agent: ___________________________________ Title: ________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Date: ___________________________ Phone Number: ___________________________ Instructions for Completing Other Tobacco Product Distributor's Excise Tax Return What Is the OTP-M? The OTP-M return is used to report all transactions related to the distribution of Other Tobacco Products in Indiana. Who Must File? IC 6-7-2 Sec. 2. As used in this chapter, "Distributor" means a person who: (1) Manufactures, sells, barters, exchanges, or distributes tobacco products in Indiana to retail dealers for purpose of resale; (2) Purchases tobacco products directly from a manufacturer of tobacco products; or (3) Purchases for resale tobacco products from a wholesaler, jobber, or distributor outside of Indiana who is not a distributor holding a license issued under this chapter. Reporting Requirements The holder of an Other Tobacco Products Distributor's License must complete an Other Tobacco Product Distributor's Excise Tax Return (OTP-M) with the Department of Revenue on or before the 15th day of the month following the month in which the liability for the tax accrues. Payment of the excise tax due shall accompany the return. A return must be filed even if there is no activity within Indiana during the reporting period. Mail the return, supporting schedule, and payment to: Indiana Department of Revenue P.O. Box 901 Indianapolis, IN 46206-0901 To be considered timely filed, monthly returns must be filed on or before the 15th day of the month immediately following the last day of the month being reported. If the 15th day of the month falls on a Saturday, a Sunday, a national legal holiday, or a statewide holiday, the due date is the next succeeding day that is not a Saturday, a Sunday, or such holiday. Penalty Taxpayers who fail to file timely are subject to a penalty of $5 or 10% of tax due, whichever is greater. Questions If you need further assistance, you can contact us at (317) 615-2710 or at INCigTax@dor.in.gov. Section A: Taxpayer Information Indicate the month and year for which the return is being filed in the appropriate spaces provided. Name (As It Appears on License) ­ Indicate the entity name as it appears on the Indiana Other Tobacco Products Distributor's License. Physical Address ­ Indicate the actual location of your business by providing the street address, city, state, and ZIP Code. Note: A post office box is not acceptable as a business location address. Mailing Address ­ Indicate the mailing address for your business. Include the street address, post office box, city, state, and ZIP Code. Email Address ­ Provide your business email address. Distributor License Number ­ Indicate the license number provided on your Distributor's License. Federal Identification Number ­ Indicate the nine-digit federal employer identification number (FEIN). Indiana Taxpayer Identification Number ­ Indicate the ten-digit Indiana taxpayer identification number (TID). If you do not have an Indiana TID, leave this space blank and one will be assigned to you. Section B: Excise Tax Calculation Moist Snuff products are reported in ounces. All Other Tobacco Products except Moist Snuff are reported at wholesale price. Line 1 - Enter the wholesale price total in Column A. Enter the number of ounces in Column B. The amount totals will be the amounts reported on Line 13 of Schedule OTP-M-S. Line 2 - Enter the wholesale price total in Column A. Enter the number of ounces in Column B. The amount totals will be the amounts reported on Line 14 of Schedule OTP-M-S. Line 3 - Enter the wholesale price total in Column A. Enter the number of ounces in Column B. The amount totals will be the amounts reported on Line 15 of Schedule OTP-M-S. Line 4 - Enter the wholesale price total in Column A. Enter the number of ounces in Column B. The amount totals will be the amounts reported on Line 16 of Schedule OTP-M-S. Line 5 - Enter the wholesale price total in Column A. Enter the number of ounces in Column B. The amount totals will be the amounts reported on Line 17 of Schedule OTP-M-S. American LegalNet, Inc. www.FormsWorkFlow.com Line 6 - Enter the wholesale price total in Column A. Enter the number of ounces in Colum