Form 811 - Revenue Stamp Transaction

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ARIZONA FORM
Luxury
Revenue Stamp Transaction
Tax
811
Prepare in triplicate.
DATE
PURCHASER
TAXPAYER I.D. NO. (EIN or SSN)
Department Use Only
Cash Sale
ADDRESS
BOND NUMBER
Bond Sale
CITY
STATE
ZIP CODE
GROSS PURCHASES THIS MONTH*
Bond Payment Received
$
CIGARETTE
QUANTITY
x RATE
= GROSS
SERIAL NO.
SERIAL NO.
FROM
TO
Fuson Rolls (20s)
B
$ 35,400.00 (1.18 ea)
$
30,000 per roll
FROM
TO
R
$ 30,000.00 (1.00 ea)
$
FROM
TO
Fuson Rolls (TF)
30,000 per roll
G
$
0.00
$
0.00
FROM
TO
Fuson Rolls (25s)
M
M
B
$ 17,700.00 (1.475 ea) $
12,000 per roll
FROM
TO
R
$ 15,000.00 (1.25 ea)
$
B
B
FROM
TO
Fuson Rolls (25s)
T
T
B
$ 10,620.00 (1.475 ea) $
7,200 per roll
FROM
TO
A
A
R
$ 9,000.00 (1.25 ea)
$
FROM
TO
Fuson Rolls (20s)
3,000 per roll
B
$ 3,540.00 (1.18 ea)
$
X
X
FROM
TO
C
C
R
$ 3,000.00 (1.00 ea)
$
TOTAL GROSS: $
DISCOUNTS
GROSS
RATE
DISCOUNT
NET
1
st
$36,000.00 Gross: $
x
4%
−
$
=
$
2
nd
$36,000.00 Gross: $
x
3%
−
$
=
$
Over $72,000.00 Gross: $
x
2%
−
$
=
$
TOTAL DISCOUNTS: $
(
)
: $
NET
=
−
*Gross monthly purchases exceeding $165,000 will forfeit all discounts on the fi rst $72,000 gross.
APPROVED: LICENSE & REGISTRATION
By
NAME
DATE
PAID PREPARER
PURCHASER
By
STAMPS RECEIVED BY
DATE
EIN/SSN
DATE
AUTHORIZED SIGNATURE
DATE
MAIL TO: Arizona Department of Revenue, Tobacco Tax Section, 1600 West Monroe, Phoenix, AZ, 85007
ADOR 14-2011 (8/04)
Previous 74-2011 (11/02)

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