Arizona Form 840 - Cigarette Distributor'S Claim For Refund Of Cigarette Taxes Paid
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1
2Cigarette Distributor’s Claim for
Luxury
Arizona Form 840
Refund of Cigarette Taxes Paid
Tax
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 prior to completing this claim.
(A)
(B)
(C)
PKG
NUMBER OF STAMPED
AMOUNT
PACKAGES OF CIGARETTES
TAX RATE
OF TAX PAID
Packages of stamped cigarettes
1a Blue:
$2.00
$
returned to out-of-state supplier. Attach
20s
original copy of manufacturer’s affidavit
for the State of Arizona.
1b Red:
$1.00
$
2a Blue:
$2.50
$
25s
2b Red:
$1.25
$
Returned number of stamps which have
been spoiled by improper affixation or
3a Blue:
$2.00
$
20s
are surrendered for redemption.
3b Red:
$1.00
$
4a Blue:
$2.50
$
25s
4b Red:
$1.25
$
5 Total ............................................................................................................................... 5
$
6 Less Purchase Discount: See instructions before completing lines 6a and 6b.
6a Enter the percentage of discount (2% - 4%) in decimal form (.02 - .04) .................. 6a
6b Amount of discount: Multiply line 5 by line 6a ......................................................... 6b $
7 NET REFUND CLAIMED: Subtract line 6b from line 5 ................................................. 7
$
I have read this claim and any attachments with it. Under penalties of perjury, I declare that to the best of my knowledge and belief, they are true,
correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
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 11025 (9/13)
Previous ADOR 14-2012
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