Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 10

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AZ FORM 819NR

Schedule C-3

Sales of Cigars and/or Tobacco Products to Other Arizona Licensed Distributors Who Have Agreed to Pay the Tax

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 17.

(g)

(a)

(b)

(c)

(d)

(e)

(f)

(h)

No. of Ounces Sold

No. of Small Cigars

No. of Ounces

Sold Weighing

No. of Cigars Sold

Smoking Tobacco,

Sold

Name and Address of

Date

Invoice

not more than

for

Snuff, Fine Cut

Cavendish,

Chewing, etc.

Who the Product was Sold To

Shipped

Date

Number

3 lbs/1000

$.05 or Less

More than $.05

Plug or Twist

1. Total this sheet ...............................................................................................................................

2. Total all sheets ..............................................................................................................................

3. Total sold this month ......................................................................................................................

$.263 per 20

$.130 per 3

$.130 each

$.133 per oz.

$.033 per oz.

$.263 per 20

$.130 per 3

$.130 each

$.133 per oz.

$.033 per oz.

TOTAL RATES ...............................................................................................................................

4. Net non-taxable sales this month...................................................................................................

5. Total Non-Taxable Sales This Month Enter here and on page 1, line 5 .....................................................................................................................................................................

Page 10 of 17

ADOR 14-5322f (8/05)