Form 819 - Distributor'S Monthly Return Of Cigars And Tobacco Products Received
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1Arizona Form
Distributor’s Monthly Return of Cigars and Tobacco Products Received
819
This return is due the 20th day of the month following the reporting period.
Amended Return
Final Return (CANCEL LICENSE)
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
See Rates and Instructions before completing this form.
1 Total tax on tobacco products received: Enter the amount shown on Schedule A, line 5 .............................
1 $
Deductions:
2 Sold on non-offset Indian reservations: Enter the amount on Schedule B-1, line 12 .. 2 $
3 Sold on self-collecting offset Indian reservations:
3a Enter the amount shown on Schedule B-2, line 7 ................. 3a $
3b Enter the amount shown on Schedule B-3, line 7 ................. 3b $
3c Total: Add lines 3a and 3b ..................................................................................... 3c $
4 Sold on ADOR-collected offset Indian reservations:
4a Enter the amount shown on Schedule B-4 line 3 .................. 4a $
4b Enter the amount shown on Schedule B-5, line 12 ............... 4b $
4c Total: Add lines 4a and 4b ..................................................................................... 4c $
5 Exported from the state: Enter the amount shown on Schedule C, line 5 ................... 5 $
6 Returned to suppliers: Enter the amount shown on Schedule D, line 5 ...................... 6 $
7 Purchased tax paid from other Arizona licensed distributors: Enter the amount
shown on Schedule E-1, line 5 ..................................................................................... 7 $
8 Sold to Arizona licensed distributors (who will pay the tax): Enter the amount
shown on Schedule E-2, line 5 ..................................................................................... 8 $
9 Sold to military installations .......................................................................................... 9 $
10 Total Deductions: Add lines 2, 3c, 4c, 5, 6, 7, 8 and 9 ................................................................................ 10 $
11 TOTAL TAX DUE: Subtract line 10 from line 1 ............................................................................................. 11 $
Declaration of preparer (other than taxpayer) is based on all
I have read this claim and any attachments with it. Under penalties
information of which preparer has any knowledge.
of perjury, I declare that to the best of my knowledge and belief,
they are correct and complete.
PREPARER’S SIGNATURE
TAXPAYER’S OR AUTHORIZED AGENT’S SIGNATURE
PREPARER’S TIN
DATE
TITLE
DATE
Please mail to: Arizona Department of Revenue, Tobacco Tax, PO Box 29019, Phoenix, AZ 85038-9019
ADOR 11045 (9/13)
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