Form 805 - Reservation Retailer'S Monthly Report
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1
2LUXURY TAX
ARIZONA FORM
ARIZONA DEPARTMENT OF REVENUE
805
TOBACCO TAX SECTION
1600 W Monroe
Phoenix AZ 85007
RESERVATION RETAILER'S MONTHLY REPORT
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.
Registered Retailer - Name
Registration No
Taxpayer ID (EIN or SSN )
Address - Mailing
Address - Business Location
City
State
ZIP Code
City
State
ZIP Code
READ INSTRUCTIONS ON REVERSE SIDE
1. Total number of packs of cigarettes sold. .......................................................................
2. Total number of packs of cigarettes sold to enrolled members of the tribe. .....................
3. Total sales in dollars of other tobacco products ..............................................................
4. Percentage of sales of other tobacco products to enrolled members of the tribe .............
Declaration of preparer (other than retailer) is based on all information of
I have read this report and any attachments with it. Under penalties of perjury,
which preparer has any knowledge.
I declare that to the best of my knowledge and belief, they are correct and complete.
Preparer's Signature
Retailer's Signature
Preparer's TIN
Date
Title
Date
ADOR 20-2043 (12/94)
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