Arizona Form 840-A - Cigarette Distributor'S Affidavit For Rebate Of Cigarette Taxes Paid Page 2

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AZ FORM 840-A
GENERAL INSTRUCTIONS:
SPECIFIC INSTRUCTIONS:
You must file this form to receive a rebate for cigarette
Lines 1 through 8, Columns A through D: Enter the
taxes paid.
registration number, name, invoice date, invoice number,
and the number of stamped packages for each sale on a
Prepare this form for each rebate. File the original
reservation with an offsetting tribal tax. List packages of
with the Arizona Department of Revenue. Retain a
20 cigarettes and packages of 25 cigarettes on separate
copy of the form with all substantiating documentation
lines.
for at least four years, subject to inspection by the
Department.
Lines 1 through 8, Column E: Enter the appropriate
tax rate for each package of cigarettes listed in column
You must attach a copy of all applicable invoices of sale
D for which a rebate is being requested (up to $1.00 for
to this form.
packages of 20 cigarettes and up to $1.25 for packages
of 25 cigarettes).
You must provide your taxpayer identification number
on the form. A taxpayer identification number is either
Lines 1 through 8, Column F: Multiply the number
your Federal Employer Identification Number (EIN) or
of stamped packages in column D by the tax rates in
your Social Security Number (SSN), if you are a sole
column E to calculate the amount of rebate due.
proprietor with no employees.
Line 9: Add the amounts on lines 1 through 8 in
The Licensee or Authorized Agent must sign the form.
column F. Enter the total amount here.
If you pay a preparer to complete the form, the preparer
must sign the form and include his or her identification
number.
ADOR 11073 (9/13)
Page 2 of 2
Previous ADOR 14-2041 (11/02)

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