Arizona Form 800-25 - Cigarette Distributor'S Monthly Return - Arizona Department Of Revenue Page 5

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AZ FORM 800-25

Schedule A-4

Nonparticipating 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 12. Please provide the following information with respect to all Nonparticipating Manufacturer’s (NPM) cigarettes (excluding

roll-your-own tobacco). A list of Nonparticipating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona Attorney General’s web site,

If you have had no NPM activity during the month above, complete and submit the Resident Distributor’s Certiﬁ cation of No Nonparticipating Manufacturer’s Activity,

page 9.

NONPARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

(e)

Invoice

Quantity

Nonparticipating Manufacturer’s Name

Name and Address of Person(s) from

Individual

and Address

Whom Purchased

Date

Number

Brand Family

Packs of 25

Cigarettes

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

Page 5 of 12

ADOR 14-2042f (6/05)