Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 3

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AZ FORM 819NR
Schedule A-3
Participating Manufacturer’s Roll-Your-Own Tobacco Sold in Arizona
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 14. Please provide the following information with respect to all Participating Manufacturer’s roll-your-own tobacco on which
you paid state excise taxes. A list of Participating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona Attorney General’s web site,
PARTICIPATING MANUFACTURER’S BRANDS:
(a)
(b)
(c)
(d)
Name and Address of
Quantity
Who the Product was Sold To
Participating Manufacturer’s Name
Brand Family
in Ounces
TOTAL ........................................................................................................................................................................................................................................
Page 3 of 17
ADOR 14-5322f (8/05)

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