Arizona Form 819nr - Nonresident Distributor'S Monthly Return Of Cigars And Tobacco Products Sold (For Nonresident Licensed Distributors) - Arizona Department Of Revenue Page 7

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AZ FORM 819NR

Schedule B-3

Sales of Cigars and/or Tobacco Products Sold on Arizona Indian Reservations That Have Enacted and Collect Their Own Tax

for both the §42-3251 and the §42-3251.01 Tax Rates

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

RESERVATION NAME

FOR THE MONTH OF

MONTH YYYY

Include copies of invoices. Please see instructions and deﬁ nitions beginning on page 16.

“-1” R

ETAILERS

No. of Small

No. of Ounces Sold

(Include allocated tax free sales to “-2” Retailers.)

Cigars Sold

No. of Cigars Sold

Smoking Tobacco,

No. of Ounces Sold

Invoice

weighing not more

for

Snuff, Fine Cut

Cavendish, Plug,

Registration Number

Name of Purchaser

Date

Number

than 3 lbs/1000

$.05 or less

more than $.05

Chewing, etc.

or Twist

1. Totals ...........................................................................................................................................

$.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.............................................................................................................................

2. Total amount due distributor for taxes paid but not collected ......................................................

3. Total amount due distributor for taxes paid but not collected from “-1” Retailers (sum of line 2) ..................................................................................................................................

“-2” R

ETAILERS

(Do not include the allocated tax free sales listed under “-1” Retailers.)

Invoice

Small Cigars

Cigars

Ounces

Registration Number

Name of Purchaser

Date

Number

3 lbs/1000 or less

$.05 or less

more than $.05

Tobacco, etc.

Cavendish, etc.

4. Totals ...........................................................................................................................................

$.223 per 20

$.110 per 3

$.110 each

$.113 per oz.

$.028 per oz.

$.223 per 20

$.110 per 3

$.110 each

$.113 per oz.

$.028 per oz.

§42-3251 and §42-3251.01 RATES ............................................................................................

5. Net amount due distributor for taxes paid but not collected ........................................................

6. Total amount due distributor for taxes paid but not collected from “-2” retailers (sum of line 5)....................................................................................................................................

7. Total amount due distributor for taxes paid but not collected (sum of lines 3 and 6). Enter here and on page 1, line 3b ...................................................................................

Page 7 of 17

ADOR 14-5322f (8/05)