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Arizona Form 800nr - Cigarette Distributor'S Monthly Return For Nonresident Licensed Distributors - Arizona Department Of Revenue Page 3

AZ FORM 800NR

Schedule A-4

Nonparticipating Manufacturer’s Cigarettes Sold in Arizona (except roll-your-own tobacco)

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

, 20____

Please see instructions and deﬁ nitions beginning on page 7. Please provide the following information with respect to all Nonparticipating Manufacturer’s (NPM) cigarettes (excluding

roll-your-own tobacco) that you shipped to this state. 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 Nonresident Distributor’s Certiﬁ cation of No

Nonparticipating Manufacturer’s Activity, page 5.

NONPARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

(e)

Invoice

Quantity

Nonparticipating Manufacturer’s

Name and Address of

from sale listed in column (b)

Individual

Name and Address

Who the Product Was Sold To

Brand Family

Date

Number

Packs of 20

Packs of 25

Cigarettes

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

Page 3 of 7

ADOR 14-2013 (8/05)