Form 840-A - Cigarette Distributor'S Affi Davit For Tax Rebate Of Cigarette Taxes Paid

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ARIZONA FORM
Luxury
840-A
Cigarette Distributor’s Affi davit for
Tax
Rebate of Cigarette Taxes Paid
Arizona Department of Revenue, Tobacco Tax, 1600 West Monroe, Phoenix, AZ 85007
Please mail to:
LICENSED DISTRIBUTOR’S NAME (as appears on your license)
TOBACCO LICENSE NO.
TAXPAYER I.D. (EIN or SSN)
MAILING ADDRESS
ADDRESS OF BUSINESS LOCATION
CITY
STATE
ZIP
CITY
STATE
ZIP
NAME OF CONTACT PERSON
TELEPHONE NO.
(
)
Read instructions on reverse side.
SALES TO INDIAN RESERVATIONS WITH OFFSETTING TRIBAL TAX
(A)
(B)
(C)
(D)
(E)
(F)
NO. OF
INVOICE
STAMPED
REGISTRATION NO. / NAME
DATE
INVOICE NUMBER
PACKAGES
TAX RATE
REBATE DUE
1
$
$
2
$
$
3
$
$
4
$
$
5
$
$
6
$
$
7
$
$
8
$
$
9 Total ........................................................................................................................................................ 9 $
10 Less Purchase Discount (2% of face value). If licensed distributor has received a discount of greater
than 2%, please contact the Luxury Tax Section at (602) 542-4643....................................................... 10 $
11 TOTAL AMOUNT OF REBATE DUE....................................................................................................... 11 $
I hereby certify that the above listed packages of cigarettes were sold to retailers that reside on a reservation that has imposed an
offsetting tobacco tax. Therefore, I am requesting a rebate for the packages of cigarettes that had either the blue tax stamp or the
red tax stamp affi xed to them. I have attached a copy of the invoice for all sales.
►
LICENSEE OR AUTHORIZED AGENT’S SIGNATURE
DATE
TITLE
►
PREPARER’S SIGNATURE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PREPARER’S TIN
DATE
PREPARER’S ADDRESS
ADOR 14-2041 (11/02)

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