Form 841 - Department Of Revenue Tobacco Tax Section

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LUXURY TAX
ARIZONA FORM
ARIZONA DEPARTMENT OF REVENUE
841
TOBACCO TAX SECTION
1600 W Monroe
Phoenix AZ 85007
CIGARETTE DISTRIBUTOR'S REPORT OF CIGARETTES RECEIVED IN PACKAGES OF OTHER
THAN PACKAGES OF 20 OR 25 CIGARETTES.
For the Month of __________________________ 19 __________
This return must be filed with the Department of Revenue not later than the 20th day of the 1st month
following the month for which this return is made.
Licensed Distributor-Name
Tobacco License No
Taxpayer ID (EIN or SSN)
Address- Mailing
Address-Business Location
City
State
ZIP Code
City
State
ZIP Code
READ INSTRUCTIONS ON REVERSE
1. CIGARETTES RECEIVED:
a. Number of packages of 10
cigarettes per pack =____________x 10 = (a) ____________________
b. Number of packages of 12
cigarettes per pack =____________x 12 = (b) ____________________
c. Number of packages of 16
cigarettes per pack =____________x 16 = (c) ____________________
d. Number of packages of ____ cigarettes per pack =____________x____ = (d) ___________________
e. Number of packages of ____ cigarettes per pack =____________x____ = (e) ___________________
f. Number of packages of ____ cigarettes per pack =____________x____ = (f) ___________________
A. Total cigarettes received
A. ___________________________
2. NON-TAXABLE CIGARETTES
g. Cigarettes sold tax free to Indian reservations - Schedule A ................................... (g) ______________________
h. Cigarettes sold under § 42-1241 to Indian reservations - Schedule B ..................... (h) ______________________
TAX COMPUTATION
4. a ___________________ taxable cigarettes @ $0.029 per cigarette =
Tax Due: $____________________________
b ___________________ taxable cigarettes @ $0.02 per cigarette=
Tax Due: $____________________________
Declaration of preparer (other than taxpayer) is based on all information of
I have read this claim and any attachments with it. Under penalties of perjury, I
which preparer has any knowledge.
declare that to the best of my knowledge and belief, they are correct and
Preparer's Signature
Licensee Authorized Agent's Signature
Preparer's TIN
Title
ADOR 20-2026 (12/94)

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