Arizona Form 805 - Reservation Retailer'S Monthly Report
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1
2Instructions
Arizona Form
Reservation Retailer’s Monthly Report
805
This return must be filed with the Arizona Department of Revenue no later than the
20th day of the 1st month following the month for which this return is made.
Registered Retailer – Name
Registration Number:
Taxpayer I.D. Number:
Mailing Address
Period Beginning:
Period Ending:
NEW
M
M D D Y Y Y Y
M
M D D Y Y Y Y
City
State ZIP Code
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Business Location Address
NEW
City
State ZIP Code
Name of Contact Person
Telephone No.
NEW
NEW
E-mail Address
Fax No.
NEW
NEW
81 PM
80 RCVD
See instructions on reverse side.
1 Total number of packs of cigarettes sold .........................................................................
1
2 Total number of packs of cigarettes sold to enrolled members of the tribe .....................
2
3 Total sales in dollars of other tobacco products ..............................................................
3 $
00
4 Percentage of sales of other tobacco products to enrolled members of the tribe ...........
4
%
Declaration of preparer (other than retailer) is based on
I have read this report and any attachments with it.
all information of which preparer has any knowledge.
Under penalties of perjury, I declare that to the best of
my knowledge and belief, they are correct and complete.
PREPARER’S SIGNATURE
RETAILER’S SIGNATURE
PREPARER’S TIN
DATE
TITLE
DATE
Print Form
MAIL TO: Arizona Department of Revenue
Tobacco Tax Section
PO Box 29019
Phoenix, AZ 85038-9019
ADOR 11075 (9/13)
Previous 14-2043 (03)
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