Arizona Form 819 - Schedule C, C-1, C-2 Page 3
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3SCHEDULE C-2
AZ FORM 819
Schedule C-2
Sheet ___ of ___
Export of Nonparticipating 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 Nonparticipating Manufacturer’s (NPM) roll-your-own tobacco that
you exported from Arizona. 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 Resident Distributor’s Certification of No Nonparticipating Manufacturer’s
Activity.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Nonparticipating 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 ..................................................................................................................................................................
3
Page 14
ADOR 11045 (9/13)
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