Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 4

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AZ FORM 819NR

Schedule A-4

Nonparticipating 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 Nonparticipating Manufacturer’s (NPM) roll-your-own tobacco

on which you paid state excise taxes. A list of Nonparticipating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona Attorney

General’s web site, If you have had no NPM activity during the month above, complete and submit the Nonresident Distributor’s Certiﬁ cation of No Nonparticipating

Manufacturer’s Activity, page 12.

NONPARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

(e)

Invoice

Nonparticipating Manufacturer’s

Name and Address of

from sale listed in column (b)

Quantity

Name and Address

Who the Product Was Sold To

Date

Number

Brand Family

in Ounces

TOTAL .................................................................................................................................................................................................................................................

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ADOR 14-5322f (8/05)