Arizona Form 841 - Cigarette Distributor'S Monthly Report Of Cigarettes Received In Packages Other Than Of 20 Or 25 Cigarettes
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4Instructions
Arizona Form
Cigarette Distributor’s Monthly Report of Cigarettes Received
Luxury
in Packages Other Than of 20 or 25 Cigarettes
Tax
841
This return must be filed with the Arizona Department of Revenue not later than the
20th day of the 1st month following the month for which this return is made.
Amended Return
Final Return
(CANCEL LICENSE)
Licensed Distributor’s Name (as appears on your license)
Tobacco License No.:
Taxpayer I.D. No.:
Business (or dba) Name
Period Beginning:
Period Ending:
M
M D D Y Y Y Y
M
M D D Y Y Y Y
Mailing Address
City
State Zip
NEW
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Business Location Address
City
State Zip
NEW
Name of Contact Person
Telephone No.
NEW
(with area code)
NEW
E-mail Address
Fax No.
NEW
(with area code)
NEW
81 PM
80 RCVD
Read instructions beginning on page 4.
1
CIGARETTES RECEIVED (Attach copies of invoices):
PKGS OF
NO. OF PKGS
QTY PER PKG
TOTAL
a
10
x
10
=
b
12
x
12
=
c
16
x
16
=
d
x
=
e
x
=
f
x
=
g Total Cigarettes Received............................................................................................ 1g
2
NON-TAXABLE CIGARETTES:
TOTAL
h Cigarettes sold tax-free to Indian reservations - Schedule A ..
i
Cigarettes sold under §42-3251 and §42-3251.01 to Indian
reservations - Schedule B ......................................................
j
Exported from state - Schedule C ..........................................
k Cigarettes returned to suppliers - Schedule D........................
l
Total Non-Taxable Cigarettes ...................................................................................... 2l
3
TAXABLE CIGARETTES RECEIVED: Subtract line 2l from line 1g; enter the amount ... 3
TAX COMPUTATION
TAX DUE
4a
taxable cigarettes at $0.059 per cigarette = $
4b
taxable cigarettes at $0.05 per cigarette
= $
5
TOTAL TAXABLE CIGARETTES........................................................... 5
$
I have read this claim and any attachments with it. Under penalties of perjury, I declare that to the best of my knowledge and belief, they are true,
correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
TAXPAYER’S OR AUTHORIZED AGENT’S SIGNATURE
DATE
TITLE
PREPARER’S SIGNATURE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PREPARER’S TIN
DATE
PREPARER’S ADDRESS
Please mail to: Arizona Department of Revenue, Tobacco Tax, PO Box 29019, Phoenix, AZ 85038-9019
ADOR 11039 (9/13)
Previous 14-2026 (11/02)
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