Arizona Form 819nr - Schedule C-3, D Page 2

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SCHEDULE D
AZ FORM 819NR
Schedule D
Sheet ___ of ___
Credit for Cigars and Tobacco Products Returned by Retailers During the Month
LEGAL BUSINESS NAME
BUSINESS (or dba) NAME
TOBACCO LICENSE NO.
FOR THE MONTH OF
MONTH YYYY
Do not show returns by registered Native American retailers. Attach copies of credit memos/invoices. Please see instructions before completing this form.
(g)
(a)
(b)
(c)
(d)
(e)
(f)
(h)
No. of Ounces
No. of Small Cigars
No. of Cigars
No. of Cigars
No. of Ounces
Returned Weighing
Returned Selling
Returned Selling
Returned of Smoking
Returned of
Name and Address of
Date
Credit Invoice
not more than
for
for
Tobacco, Snuff, Fine
Cavendish,
Cut Chewing, etc.
Who Returned the Product
Returned
Date
Number
3 lbs/1000
$.05 or Less
More than $.05
Plug or Twist
1 Total this sheet .......................................................................................................................... 1
2 Total all other sheets ................................................................................................................ 2
3 Total product returned this month: Add lines 1 and 2 ............................................................... 3
$.441 p er 20
$.218 p er 3
$.223 p er oz.
$.055 p er oz.
$.441 per 20
$.218 per 3
$.218 each
$.223 per oz.
$.055 per oz.
×
×
×
$.218 each
×
×
TOTAL RATES ...........................................................................................................................
4 Net amount to be deducted for returned product this month: See instructions ........................ 4
5 Total amount to be deducted for returned product this month: Add the amounts in columns d, e, f, g, and h of line 4. Enter here and on page 1, line 6 .................................
5
Page 11
ADOR 10531 (9/13)

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