Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue

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ARIZONA FORM
Nonresident Distributor’s Monthly Return of Cigars and
819NR
Tobacco Products Sold
(For Nonresident Licensed Distributors)
This return must be fi led with the Arizona Department of Revenue not later than
the 20th day of the 1st month following the month for which this return is made.
FOR THE MONTH OF (enter full month and 4-digit year)
TOBACCO LICENSE NO.
TAXPAYER ID (EIN OR SSN)
MONTH YYYY
LEGAL BUSINESS NAME
BUSINESS (OR DBA) NAME
MAILING ADDRESS
ADDRESS OF BUSINESS LOCATION
Check if new.
Check if new.
CITY
STATE
ZIP
CITY
STATE
ZIP
NAME OF CONTACT PERSON
TELEPHONE NUMBER WITH AREA CODE
Check if new.
Check if new.
E-MAIL ADDRESS
FAX NUMBER WITH AREA CODE
Check if new.
Check if new.
See Rates and Instructions beginning on page 13.
1 Total tax on tobacco products sold: Enter the amount shown on Schedule A, line 5 ....................................
1
$
Deductions:
2 Sold to non-offset Indian reservations: Enter the amount on Schedule B-1, line 11 ... 2
$
3 Sold on self-collecting offset Indian reservations:
3a Enter the amount shown on Schedule B-2, line 7 ................ 3a
$
3b Enter the amount shown on Schedule B-3, line 7 ................ 3b
$
3c Total: Add lines 3a and 3b ..................................................................................... 3c
$
4 Sold on ADOR-collected offset Indian reservations:
4a Enter the amount shown on Schedule B-4 line 3 ................. 4a
$
4b Enter the amount shown on Schedule B-5, line 11 .............. 4b
$
4c Total: Add lines 4a and 4b ..................................................................................... 4c
$
5 Sold to Arizona licensed distributors (who will pay the tax). Enter the amount
shown on Schedule C-3, line 5 .................................................................................... 5
$
6 Returned by retailers: Enter the amount shown on Schedule D, line 5....................... 6
$
7 Sold to military installations .......................................................................................... 7
$
8 Total Deductions: Add lines 2, 3c, 4c, 5, 6 and 7. .......................................................................................
8
$
9 TOTAL TAX DUE: Subtract line 8 from line 1 ...............................................................................................
9
$
Declaration of preparer (other than taxpayer) is based on all
I have read this claim and any attachments with it. Under penalties
information of which preparer has any knowledge.
of perjury, I declare that to the best of my knowledge and belief,
they are correct and complete.
PREPARER’S SIGNATURE
TAXPAYER’S OR AUTHORIZED AGENT’S SIGNATURE
PREPARER’S TIN
DATE
TITLE
DATE
MAIL TO: Arizona Department of Revenue
Tobacco Tax Section, 1600 West Monroe, Phoenix, AZ 85007
ADOR 14-5322f (8/05)

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