Arizona Form 819nr - Schedule B-1, B-2, B-3

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SCHEDULE B-1

AZ FORM 819NR

Schedule B-1

Sheet ___ of ___

Sales of Cigars and/or Tobacco Products Sold on Arizona Indian Reservations That Have Not Enacted Their Own Tax

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

RESERVATION NAME

FOR THE MONTH OF

MONTH YYYY

Include copies of invoices. Please see instructions before completing this form.

(a)

(b)

(c)

(d)

(e)

“-1” R

No. of Small

No. of Ounces Sold

ETAILERS

Cigars Sold

No. of Cigars Sold

Smoking Tobacco,

No. of Ounces Sold

Invoice

weighing not more

for

Snuff, Fine Cut

Cavendish, Plug,

Registration Number

Name of Purchaser

Date

Number

than 3 lbs/1000

$.05 or less

more than $.05

Chewing, etc.

or Twist

1 Totals ........................................................................................................................................

2 Quantity of line 1 sold tax free ..................................................................................................

$.441 p er 20

$.218 p er 3

$.223 p er oz.

$.055 p er oz.

$.218 each

TOTAL RATES .........................................................................................................................

3 Net amount due distributor for taxes paid but not collected: See instructions.........................

4 Quantity of line 1 sold on which only the §42-3251 and §42-3251.01 rates were collected ....

$.218 p er 20

$.108 p er 3

$.110 p er oz.

$.027 p er oz.

$.218 per 20 $.108 per 3 $.108 each $.110 per oz. $ .027 per oz.

$.108 each

§42-3052 and §42-3371 RATES ..............................................................................................

5 Net amount due distributor for taxes paid but not collected: See instructions.........................

6 Subtotal: For each of columns a, b, c, d, and e, add line 3 and line 5. Enter the amount ......

7 Total amount due distributor for taxes paid but not collected from “-1” Retailers: Add the amounts in columns a, b, c, d, and e of line 6 and enter the total .................................

“-2” R

ETAILERS

Invoice

Small Cigars

Cigars

Ounces

Registration Number

Name of Purchaser

Date

Number

3 lbs/1000 or less

$.05 or less

more than $.05

Tobacco, etc.

Cavendish, etc.

8 Totals ........................................................................................................................................

9 Quantity of line 8 sold tax free ..................................................................................................

$.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 .........................................................................................................................

10 Net amount due distributor for taxes paid but not collected: See instructions......................... 10

11 Total amount due distributor for taxes paid but not collected from “-2” retailers: Add the amounts in columns a, b, c, d, and e of line 10 and enter the total ................................. 11

12 GRAND TOTAL amount due distributor for taxes paid but not collected: Add lines 7 and 11. Enter the total here and on page 1, line 2 ...................................................... 12

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ADOR 10531 (9/13)