Arizona Form 819nr - Schedule A, A-3, A-4 Page 3

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SCHEDULE A-4

AZ FORM 819NR

Schedule A-4

Sheet ___ of ___

Nonparticipating Manufacturer’s Roll-Your-Own Tobacco Sold in Arizona

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Please see deﬁ nitions and instructions before completing this form. Please provide the following information with respect to all Nonparticipating Manufacturer’s (NPM) roll-your-own

tobacco on which you paid state excise taxes. A list of Nonparticipating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona

Attorney General’s web site, If you have had no NPM activity during the month above, complete and submit the Nonresident Distributor’s Certiﬁ cation of No

Nonparticipating Manufacturer’s Activity.

NONPARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

(e)

Invoice

Nonparticipating Manufacturer’s

Name and Address of

from sale listed in column (b)

Quantity

Name and Address

Who the Product Was Sold To

Brand Family

in Ounces

Date

Number

TOTAL .................................................................................................................................................................................................................................................

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