Arizona Form 800-25 - Cigarette Distributor'S Monthly Return - Arizona Department Of Revenue Page 2

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AZ FORM 800-25

Schedule A-1

Participating Manufacturer’s Cigarettes Received in Arizona (except roll-your-own tobacco)

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Please see instructions and deﬁ nitions beginning on page 11. Please provide the following information with respect to all Participating Manufacturer’s cigarettes (excluding roll-your-own

tobacco) that you received in this state regardless of whether such cigarettes were subsequently exported. A list of Participating Manufacturers, and their brands authorized for sale

in Arizona, is maintained and updated at the Arizona Attorney General’s web site,

PARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

(e)

Name and Address of Person(s)

Invoice

from Whom Purchased

Participating Manufacturer’s Name

(if other than the participating manufacturer)

Date

Number

Brand Family

Packs of 25

TOTAL: Enter here and on Schedule E, Page 10...............................................................................................................................................................................

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ADOR 14-2042f (6/05)