Form Ador 11134 - Pact Act Statement Form
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1Arizona Department of Revenue • Tobacco Tax
PACT Act Statement
(15 U.S.C. 376(a)(1))
Federal law requires fi ling of this form by any person who intends to sell, transport, or ship cigarettes or
smoking tobacco into Arizona (or who advertises or offers to do so) from outside the state, from Indian
country, or from within Arizona if passing through points outside the state or in Indian country. This form
must be fi led before any such sale or transfer. The Arizona Department of Revenue will not consider this
statement properly fi led unless all of the requested information is accurately and completely provided.
SELLER’S INFORMATION
Name of Seller
Trade Name (if applicable)
Principle Place of Business - Address
Phone Number (with area code)
City
State
Zip Code
Address of any other place of business
Phone Number (with area code)
City
State
Zip Code
Seller’s Email Address
Web Site Address
AUTHORIZED AGENT’S INFORMATION
(must meet requirements for statutory agents found in A.R.S. Title 10 or 29)
Name of Authorized Agent
Address
Phone Number (with area code)
City
State
Zip Code
AZ
AZ
Under penalties of perjury, I/we declare that to the best of my/our knowledge and belief, the information in this statement
is true, correct and complete.
PRINT YOUR NAME
TITLE
YOUR SIGNATURE
DATE
Please mail to: Arizona Department of Revenue, Tobacco Tax, 1600 West Monroe, Phoenix, AZ 85007
ADOR 11134 (7/10)
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