Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 11

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AZ FORM 819NR

Schedule D

Credit for Cigars and Tobacco Products Returned by Retailers During the Month

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Do not show returns by registered Native American retailers. Attach copies of credit memos/invoices. Please see instructions and deﬁ nitions beginning on page 17.

(g)

(a)

(b)

(c)

(d)

(e)

(f)

(h)

No. of Ounces

No. of Small Cigars

No. of Cigars

No. of Ounces

Returned Weighing

Returned Selling

Returned of Smoking

Returned of

Name and Address of

Date

Credit Invoice

not more than

for

Tobacco, Snuff, Fine

Cavendish,

Cut Chewing, etc.

Who Returned the Product

Returned

Date

Number

3 lbs/1000

$.05 or Less

More than $.05

Plug or Twist

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

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

3. Total product returned 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 amount to be deducted for returned product this month .........................................................

5. Total amount to be deducted for returned product this month (sum of net amounts). Enter here and on page 1, line 6 ....................................................................................

Page 11 of 17

ADOR 14-5322f (8/05)