Arizona Form 800nr - Nonresident Distributor'S Certification Of No Nonparticipating Manufacturer'S Activity

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AZ FORM 800NR
Nonresident 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 PERIOD OF
M
M D D Y Y Y Y
to
M
M D D Y Y Y Y
As evidenced by my signature below, I
, do
(print/type name)
hereby certify under penalty of perjury, that during the period shown above, the distributor named above:
DID NOT pay state excise taxes on any nonparticipating manufacturer’s roll-your-own
1
tobacco required to be reported on Schedule A-4 of Form 819NR. If not checked, I
have engaged in this activity and have completed and submitted Schedule A-4 with
Form 819NR.
DID NOT affi x the excise tax stamp of the State of Arizona to or otherwise pay state
2
excise taxes for any nonparticipating manufacturer’s cigarettes required to be reported on
Schedule A-4 of Form 800NR. If not checked, I have engaged in this activity and have
completed and submitted Schedule A-4 with Form 800NR.
SIGNATURE: (Must be signed to be considered complete.)
TAXPAYER’S AUTHORIZED AGENT’S SIGNATURE
TITLE
DATE
Print
Page 7
ADOR 11026 (9/13)

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