Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 2

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AZ FORM 819NR

Schedule A

Sales of Cigars and/or Tobacco Products Shipped into Arizona During the Month

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Complete using the total rate of tax. Please see instructions and deﬁ nitions beginning on page 13. If product received in columns (g) or (h) constitutes “roll-your-own” per the deﬁ nition

on page 14, enter both here and on either Schedule A-3, if from a Participating Manufacturer, or Schedule A-4 if from a nonparticipating manufacturer.

(g)

(a)

(b)

(c)

(d)

(e)

(f)

(h)

No. of Ounces

No. of Small Cigars

No. of Cigars

No. of Ounces

Shipped Weighing

Shipped

Shipped of Smoking

Shipped of

Name and Address of

Date

Invoice

not more than

Selling for

Tobacco, Snuff, Fine

Cavendish,

Cut Chewing, etc.

Who the Product was Sold To

Received

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 taxes this month ......................................................................................................................

5. Total Tax This Month (sum of net taxes). Enter here and on page 1, line 1. ...............................................................................................................................................................

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ADOR 14-5322f (8/05)