Arizona Form 819 - Schedule B-4, B-5 Page 2
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1
2SCHEDULE B-5
AZ FORM 819
Schedule B-5
Sheet ___ of ___
Sales of Cigars and/or Tobacco Products Sold During the Month on Arizona Indian Reservations –
that have enacted but do not collect their own tax which exempts tribal members
LEGAL BUSINESS NAME
BUSINESS (OR DBA) NAME
TOBACCO LICENSE NO.
RESERVATION NAME
FOR THE MONTH OF
MONTH YYYY
Include copies of invoices. Please see instructions before completing this form.
(a)
(b)
(c)
(d)
(e)
“-1” R
No. of Small
No. of Ounces Sold
ETAILERS
Cigars Sold
No. of Cigars Sold
No. of Cigars Sold
Smoking Tobacco,
No. of Ounces Sold
Invoice
Invoice
weighing not more
for
for
Snuff, Fine Cut
Cavendish, Plug,
Registration Number
Name of Purchaser
Date
Number
than 3 lbs/1000
$.05 or less
more than $.05
Chewing, etc.
or Twist
1 Totals ........................................................................................................................................
1
2 Quantity of line 1 sold tax free ..................................................................................................
2
$.441 per 20 $.218 per 3 $.218 each $.223 per oz. $ .055 per oz.
×
$.441 per 20
×
$.218 per 3
×
$.218 each
×
$.223 per oz.
×
$.055 per oz.
TOTAL RATES .........................................................................................................................
3 Net amount due distributor for taxes paid but not collected: See instructions.........................
3
4 Quantity of line 1 sold on which only the §42-3251 and §42-3251.01 rates were collected ....
4
$.218 p er 20
$.218 per 20 $.108 per 3 $.108 each $.110 per oz. $ .027 per oz.
$.108 p er 3
$.110 p er oz.
$.027 p er oz.
×
×
×
$.108 each
×
×
§42-3052 RATES .....................................................................................................................
5 Net amount due distributor for taxes paid but not collected: See instructions.........................
5
6 Subtotal: For each of columns a, b, c, d, and e, add line 3 and line 5. Enter the amount ......
6
7 Total amount due distributor for taxes paid but not collected from “-1” Retailers: Add the amounts in columns a, b, c, d, and e of line 6 and enter the total .................................
7
“-2” R
ETAILERS
Invoice
Invoice
Small Cigars
Cigars
Cigars
Ounces
Ounces
Registration Number
Name of Purchaser
Date
Number
3 lbs/1000 or less
$.05 or less
more than $.05
Tobacco, etc.
Cavendish, etc.
8 Totals ........................................................................................................................................
8
9 Quantity of line 8 sold tax free ..................................................................................................
9
×
$.441 per 20 $.218 per 3$.218 each
$.441 per 20
×
$.218 per 3
×
$.218 each
×
$.223 per oz.
$.223 per oz. $ .055 per oz.
×
$.055 per oz.
TOTAL RATES .........................................................................................................................
10 Net amount due distributor for taxes paid but not collected: See instructions......................... 10
11 Total amount due distributor for taxes paid but not collected from “-2” retailers: Add the amounts in columns a, b, c, d, and e of line 10 and enter the total ................................. 11
12 GRAND TOTAL amount due distributor for taxes paid but not collected: Add lines 7 and 11. Enter the total here and on page 1, line 2 ...................................................... 12
Page 11
ADOR 11045 (9/13)
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