Form 800-R - Tobacco Products Tax Return
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1
2800-
FORM
R
T
P
T
R
OBACCO
RODUCTS
AX
ETURN
TIN/SSN:#
Cigarette Retailer's Monthly Return of Cigarette's Purchased for Sale within the
Navajo Nation
Please Check Appropriate Box :
Separate Return
Combined Return
Check box if AMENDED and enter correct MONTH/YEAR
(below) being "amended"
Name of Distributor
Reporting Period (Month)
OFFICE USE
(Due 15 days after end of month)
ONLY
Mailing Address
Business Location Address: (if different from above)
(Enter Whole Dollars)
Check here if mailing address has changed.
1. Total number of cigarettes purchased during the month . . . . . . . . . . . . . . . . . . . . .
(from Schedule A)
2. Total Tax on Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Total Tax on Cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(total in Line 1 * $0.05)
-
3. Tax Paid with Form 145 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Form 145 must have been timely filed)
=
4. Balance of Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Line 2 minus Line 3)
=
5. TOTAL TAX DUE (Line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
under
over
For payments
$10,000 make
Payments
$10,000 must be wire
check payable to the order of & mail to:
transferred to the following account:
Check here if payment
Office of the Navajo Tax Commission
The Navajo Nation
is made by wire transfer
Post Office Box 1903
ACH Routing #: 122105278
Window Rock, Arizona 86515-1903
Wells Fargo Bank - Window Rock Branch
Amount
Phone: (928) 871-6681
Window Rock, Arizona 86515
$
Fax: (928) 871-7608
Wire Transfer Routing #: 122105278
Website:
Tax Depository Account #: 2755351877
I declare that the information contained in this document and any attachments thereto is true and correct to
the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.
x
(
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Taxpayer or Duly Authorized Agent Signature
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y
g
g
Print or Type Name
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Telephone Number
p
Date
ONTC
TOB - Form 800R
Revised: 4/12/2011
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