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

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AZ FORM 819
Resident 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 receive any nonparticipating manufacturer’s roll-your-own tobacco required to be
1
reported on Schedule A-2 of Form 819. If not checked, I have engaged in this activity and
have completed and submitted Schedule A-2 with Form 819.
DID NOT pay state excise tax for any nonparticipating manufacturer’s roll-your-own
2
tobacco required to be reported on Schedule A-4 of Form 819. If not checked, I have
engaged in this activity and have completed and submitted Schedule A-4 with Form 819.
DID NOT export any nonparticipating manufacturer’s roll-your-own tobacco required to be
3
reported on Schedule C-2 of Form 819. If not checked, I have engaged in this activity and
have completed and submitted Schedule C-2 with Form 819.
DID NOT receive or affix the excise tax stamp of the State of Arizona to any cigarettes in
4
packages of 20 or 25 required to be reported on Schedules A-2 and A-4 of Forms 800-20
and 800-25.
If not checked, I have engaged in this activity and have completed and
submitted Schedules A-2 and A-4 with Forms 800-20 and 800-25.
SIGNATURE:
(Must be signed to be considered complete.)
►
TAXPAYER’S AUTHORIZED AGENT’S SIGNATURE
TITLE
DATE
Print
Page 18
ADOR 11045 (9/13)

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