Arizona Form 840-A - Cigarette Distributor'S Affidavit For Rebate Of Cigarette Taxes Paid

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Cigarette Distributor’s Affidavit for
Arizona Form
Luxury
Rebate of Cigarette Taxes Paid
Tax
840-A
Legal Business Name
Tobacco License No.:
Taxpayer I.D. No.:
Business (or dba) Name
Period Beginning:
Period Ending:
M
M D D Y Y Y Y
M
M D D Y Y Y Y
Mailing Address
City
State Zip
NEW
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Business Location Address
City
State Zip
NEW
Name of Contact Person
Telephone No.
NEW
(with area code)
NEW
E-mail Address
Fax No.
NEW
(with area code)
NEW
81 PM
80 RCVD
Read instructions on next page.
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) 716-7808. ....................................... 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 AUTHORIZED AGENT’S SIGNATURE
DATE
TITLE
PREPARER’S SIGNATURE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PREPARER’S TIN
DATE
PREPARER’S ADDRESS
Please mail to: Arizona Department of Revenue, Tobacco Tax, PO Box 29019, Phoenix, AZ 85038-9019
ADOR 11073 (9/13)
Previous ADOR 14-2041 (11/02)

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