Arizona Form 819nr - Nonresident Distributor'S Certification Of No Nonparticipating Manufacturer'S Activity

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AZ FORM 819NR
Nonresident Distributor’s Certification of No Nonparticipating Manufacturer’s Activity
(In Lieu of Nonparticipating Manufacturer’s Schedules)
LEGAL BUSINESS NAME/DBA NAME
TOBACCO LICENSE NO.
FOR THE MONTH OF
MON T H Y Y Y Y
As evidenced by my signature below, I __________________________________, do hereby certify
(print/type name)
M M D D Y Y Y Y
M M D D Y Y Y Y
under penalty of perjury, that during the period of
through
,
the distributor named above:
DID NOT pay state excise taxes on any nonparticipating manufacturer’s roll-your-own
1
tobacco required to be reported on Schedule A-4 of Form 819NR. If not checked, submit
Schedule A-4 with Form 819NR.
DID NOT affix the excise tax stamp of the State of Arizona to or otherwise pay state
2
excise taxes for any nonparticipating manufacturer’s cigarettes required to be reported on
Schedule A-4 of Form 800NR. If not checked, submit Schedule A-4 with Form 800NR.
NOTE:
• Distributors who do not submit Form 819NR must still check box 1 regarding
nonparticipating manufacturers roll-your-own activity.
• Distributors who do not submit Form 800NR must still check box 2 regarding
nonparticipating manufacturers cigarette activity.
SIGNATURE:
(Must be signed to be considered complete.)
►
TAXPAYER’S AUTHORIZED AGENT’S SIGNATURE
TITLE
DATE
Print Page
Page 12
ADOR 10531 (9/13)

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