Arizona Form 819 - Schedule D, E-1, E-2 Page 2

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SCHEDULE E-1

AZ FORM 819

Schedule E-1

Sheet ___ of ___

Purchases of Cigars and/or Tobacco Products Received During the Month

from another Arizona licensed distributor on which the taxes have already been paid

LEGAL BUSINESS NAME

BUSINESS (or dba) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Complete using the total rate of tax. 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 Ounces

Received of Smoking

Received Weighing

Received Selling

Received of

Date

Invoice

not more than

for

Tobacco, Snuff, Fine

Cavendish,

Cut Chewing, etc.

Name of Supplier

Received

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 received 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

$.218 each

$.223 per oz. $ .055 per oz.

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

4 Net taxes this month: See instructions ..................................................................................... 4

5 Total Taxes Paid this month by other Arizona licensed distributors: Add the amounts in columns d, e, f, g, and h of line 4. Enter here and on page 1, line 7 ........................

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ADOR 11045 (9/13)