Arizona Form 819 - Schedule C, C-1, C-2 Page 2
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3SCHEDULE C-1
AZ FORM 819
Schedule C-1
Sheet ___ of ___
Export of Participating Manufacturer’s Roll-Your-Own Tobacco
TOBACCO PRODUCT EXPORTED TO (name of state)
TOBACCO LICENSE NO.
TAXPAYER I.D. NO.
FOR THE MONTH OF
MONTH YYYY
LEGAL BUSINESS NAME
BUSINESS (or dba) NAME
Please see instructions before completing this form. Please provide the following information with respect to all Participating Manufacturer’s roll-your-own tobacco that you
exported from Arizona. A list of Participating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona Attorney General’s web site,
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Participating Manufacturer’s
Purchaser/Transferee -
Ounces of
Tax Paid?
Date
Invoice Number
Name and Address
Name and Address
Brand Family
Roll-Your-Own
(Yes/No)
1 Subtotal: This page only .........................................................................................................................................................................................................................
1
2 Total all other sheets ...............................................................................................................................................................................................................................
2
3 GRAND TOTAL: Add lines 1 and 2. Enter the amount here ..................................................................................................................................................................
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ADOR 11045 (9/13)
Page 13
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