Arizona Form 841 - Cigarette Distributor'S Monthly Report Of Cigarettes Received In Packages Of Other Than Packages Of 20 Or 25 Cigarettes Page 4
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4AZ Form 841 Page 4 of 4
Instructions
GENERAL INSTRUCTIONS:
by that number. Enter the actual number of cigarettes
on lines 1d through 1f.
You must fi le this return and pay the luxury tax if you are
a distributor of cigarettes in packages of other than 20 or
Line 1g: Add lines 1a through 1f. Enter the total
25 cigarettes within the state of Arizona.
cigarettes received.
You must fi le this return monthly and pay the tax on or
Line 2h: On Schedule A, enter any tax-free sales to
before the 20th day after the month the tax accrues.
your customers on the Indian reservation during the
month. The sale must be in the ratios provided to you
Prepare this return for each month regardless of whether
by the Department. Enter the totals from Schedule A
or not any tax is due. File the original with the Arizona
on page 1, line 2h. You may substitute a computer-
Department of Revenue. Retain a copy of the form with
generated list for the actual schedule.
all substantiating documentation for at least four years,
subject to inspection by the Department.
Line 2i: On Schedule B, enter any sales to your
customers on the Indian reservation at the rate indicated
You must provide your tobacco license number.
in §42-3251 and §42-3251.01 during the month. The
sale must be in the ratios provided to you by the
You must provide your taxpayer identifi cation number
Department. Enter the totals from Schedule B on page
on the form. A taxpayer identifi cation number is either
1, line 2i. You may substitute a computer-generated list
your Federal Employer Identifi cation Number (EIN) or
for the actual schedule.
your Social Security Number (SSN), if you are a sole
proprietor with no employees.
Line 2j: On Schedule C, enter any sales made out of
state during the month. Enter the totals from Schedule
The Licensee or Authorized Agent must sign the form.
C on page 1, line 2j. You may substitute a computer-
generated list for the actual schedule.
If you pay a preparer to complete this return, the
preparer must sign the form and include his or her
Line 2k: On Schedule D, enter any product returned
identifi cation number.
to suppliers during the month. Enter the totals from
Schedule D on page 1, line 2k. You may substitute a
Send payment with the return to the Arizona Department
computer-generated list for the actual schedule.
of Revenue. Include your taxpayer identifi cation number
on your check.
Line 2l: Add lines 2h through 2k. Enter the total here.
State law imposes a 10% penalty plus interest of the
Line 3: Subtract line 2l from 1g. Enter the total here.
amount of tax due on each return if your payment is late.
State law imposes a 5% penalty per month if you fail to
Line 4a: Enter the number of taxable cigarettes from
fi le. The combined penalties, however, cannot exceed
line 3 and multiply by the rate per cigarette of $0.059.
25%.
Enter the tax due.
SPECIFIC INSTRUCTIONS:
Line 4b: Enter the number of cigarettes from line 2i and
multiply by the rate per cigarettes $0.05. Enter the tax
ATTACH COPIES OF ALL PURCHASE INVOICES.
due.
Line 1a: Enter the number of packages of 10 cigarettes
Line 5: Add lines 4a and 4b to calculate the total
per pack and multiply by 10. Enter the actual number of
taxable cigarettes and the total tax due.
cigarettes on line 1a.
Line 1b: Enter the number of packages of 12 cigarettes
per pack and multiply by 12. Enter the actual number of
cigarettes on line 1b.
Line 1c: Enter the number of packages of 16 cigarettes
per pack and multiply by 16. Enter the actual number of
cigarettes on line 1c.
Lines 1d through 1f: Enter the number of packages of
the different number of cigarettes per pack and multiply
ADOR 14-2026 (11/02)
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