Arizona Form 800nr - Cigarette Distributor'S Monthly Report For Nonresident Licensed Distributors Page 3

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AZ Form 800NR Page 3 of 6
Non-Resident Distributor’s Certifi cation of
No Non-Participating Manufacturer’s Activity
(In Lieu of Non-Participating Manufacturer’s Schedules)
For the month _______________________, 20____
As evidenced by my signature below, I __________________________________, do hereby
(print name)
certify under penalty of perjury, that during the period of
through
, ______________________________________________________________
(Name of Licensed Distributor)
did not (check all that apply):
Sell any non-participating manufacturer’s roll-your-own tobacco required to be reported on
Schedule A-2 of Form 819NR. If not checked, submit Schedule A-2 with Form 819NR.
Sell any non-participating manufacturer’s cigarettes required to be reported on Schedule A
of Form 800NR. If not checked, submit Schedule A with Form 800NR.
NOTE:
• Distributors who do not submit Form 800NR must still check the box regarding non-
participating manufacturers cigarette activity.
• Distributors who do not submit Form 819NR must still check the box regarding non-
participating manufacturers roll-your-own activity.
TAXPAYER’S AUTHORIZED AGENT’S SIGNATURE
(Must be signed to be considered complete.)
TITLE
DATE
ADOR 14-2013 (11/02)

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