Arizona Form 800-25 - Cigarette Distributor'S Monthly Return - Arizona Department Of Revenue Page 4

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AZ FORM 800-25

Schedule A-3

Participating Manufacturer’s Cigarettes Stamped for Sale 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) for which you afﬁ xed the excise tax stamp of this state or otherwise paid state excise taxes. 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)

Name and Address of Person(s)

from Whom Purchased

(if other than the participating manufacturer)

Participating Manufacturer’s Name

Brand Family

Packs of 25

TOTAL........................................................................................................................................................................................................................................

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ADOR 14-2042f (6/05)