Arizona Form 800-25 - Cigarette Distributor'S Monthly Return - Arizona Department Of Revenue Page 9

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AZ FORM 800-25
Resident Distributor’s Certifi cation of No Nonparticipating Manufacturer’s Activity
(In Lieu of Nonparticipating Manufacturer’s Schedules)
LEGAL BUSINESS NAME/DBA NAME
TOBACCO LICENSE NO.
FOR THE MONTH OF
MON T H Y Y Y Y
As evidenced by my signature below, I __________________________________, do hereby certify
(type your name)
M M D D Y Y Y Y
M M D D Y Y Y Y
under penalty of perjury, that during the period of
through
,
the distributor named above:
DID NOT receive any nonparticipating manufacturer’s cigarettes in packages of 25
1
required to be reported on Schedule A-2 of Form 800-25. If not checked, I have engaged
in this activity and have completed and submitted Schedule A-2 with Form 800-25.
DID NOT affi x the excise tax stamp of the State of Arizona to or otherwise pay state excise
2
taxes for any nonparticipating manufacturer’s cigarettes in packages of 25 required to be
reported on Schedule A-4 of Form 800-25. If not checked, I have engaged in this activity
and have completed and submitted Schedule A-4 with Form 800-25.
DID NOT export any nonparticipating manufacturer’s cigarettes in packages of 25 required
3
to be reported on Schedule C-2 of Form 800-25. If not checked, I have engaged in this
activity and have completed and submitted Schedule C-2 with Form 800-25.
DID NOT receive or pay the excise tax on nonparticipating manufacturer’s roll-your-own
4
tobacco required to be reported on Schedules A-2 and A-4 of Form 819.
If not checked,
I have engaged in this activity and have completed and submitted Schedules A-2 and A-4
with Form 819.
SIGNATURE: (Must be signed to be considered complete.)
►
TAXPAYER’S AUTHORIZED AGENT’S SIGNATURE
TITLE
DATE
Page 9 of 12
ADOR 14-2042f (6/05)

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