Form 801-R - Tobacco Products Monthly Tax Return
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5801-
FORM
R
T
P
T
R
OBACCO
RODUCTS
AX
ETURN
TIN/SSN:#
Retailer's Monthly Return of Cigars & Tobacco Products Purchased for Sale within the
Navajo Nation
Please Check Appropriate Box :
Separate Return
Combined Return
Check box if AMENDED and enter correct MONTH/YEAR
(below) being "amended"
Name of Distributor
Reporting Period (Month)
OFFICE USE
(Due 15 days after end of month)
ONLY
Mailing Address
Business Location Address: (if different from above)
(Enter Whole Dollars)
Check here if mailing address has changed.
1. Total Tax Due on Smoking Tobacco, Snuff, etc . . . . . . . . . . . . . . . . . . . . . . . .
(from Schedule A)
2. Total Tax Due on Cavendish, etc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(f
(from Schedule B
S h d l B)
)
3. Total Tax Due on Small Cigars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(from Schedule C)
4. Total Tax Due on all other Cigars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(from Schedule D)
=
5. Tobacco Products Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(add Lines 1, 2, 3, and 4)
=
6. TOTAL TAX DUE (Line 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
under
over
For payments
$10,000 make
Payments
$10,000 must be wire
check payable to the order of & mail to:
transferred to the following account:
Office of the Navajo Tax Commission
The Navajo Nation
Check here if payment
is made by wire transfer
Post Office Box 1903
Account Number: 2755351877
Amount
Window Rock, Arizona 86515-1903
Wells Fargo Bank - Window Rock Branch
Phone: (928) 871-6681
Window Rock, Arizona 86515
$
Fax: (928) 871-7608
Bank Routing Number: 121000248
I declare that the information contained in this document and any attachments thereto is true and correct to
the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.
x
(
)
/
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Taxpayer or Duly Authorized Agent Signature
Taxpayer or Du
ly
Aut orized Agent Signature
h
Pr
Print or Type Name
int or Type Name
Telephone Number
Te ephone Num er
l
b
Date
Date
ONTC
TOB - Form 801R
Revised: 8/12/2010
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