Arizona Form 841 - Cigarette Distributor'S Monthly Report Of Cigarettes Received In Packages Other Than Of 20 Or 25 Cigarettes Page 4
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4Instructions
GENERAL INSTRUCTIONS:
Lines 1d through 1f: Enter the number of packages of
the different number of cigarettes per pack and multiply
You must fi le this return and pay the luxury tax if you are
by that number. Enter the actual number of cigarettes on
a distributor of cigarettes in packages of other than 20 or
lines 1d through 1f.
25 cigarettes within the state of Arizona.
Line 1g: Add lines 1a through 1f. Enter the total cigarettes
You must fi le this return monthly and pay the tax on or
received.
before the 20th day after the month the tax accrues.
Line 2h: On Schedule A, enter any tax-free sales to your
Prepare this return for each month regardless of whether
customers on the Indian reservation during the month.
or not any tax is due. File the original with the Arizona
The sale must be in the ratios provided to you by the
Department of Revenue. Retain a copy of the form with
Department. Enter the totals from Schedule A on page 1,
all substantiating documentation for at least four years,
line 2h. You may substitute a computer-generated list for
subject to inspection by the Department.
the actual schedule.
You must provide your tobacco license number.
Line 2i:
On Schedule B, enter any sales to your
customers on the Indian reservation at the rate indicated
You must provide your taxpayer identifi cation number on
in §42-3251 and §42-3251.01 during the month. The sale
the form. A taxpayer identifi cation number is either your
must be in the ratios provided to you by the Department.
Federal Employer Identifi cation Number (EIN) or your
Enter the totals from Schedule B on page 1, line 2i. You
Social Security Number (SSN), if you are a sole proprietor
may substitute a computer-generated list for the actual
with no employees.
schedule.
The Licensee or Authorized Agent must sign the form.
Line 2j: On Schedule C, enter any sales made out of
state during the month. Enter the totals from Schedule
If you pay a preparer to complete this return, the preparer
C on page 1, line 2j. You may substitute a computer-
must sign the form and include his or her identifi cation
generated list for the actual schedule.
number.
Line 2k: On Schedule D, enter any product returned
Send payment with the return to the Arizona Department
to suppliers during the month.
Enter the totals from
of Revenue. Include your taxpayer identifi cation number
Schedule D on page 1, line 2k. You may substitute a
on your check.
computer-generated list for the actual schedule.
State law imposes a 10% penalty plus interest of the
Line 2l: Add lines 2h through 2k. Enter the total here.
amount of tax due on each return if your payment is late.
State law imposes a 5% penalty per month if you fail to
Line 3: Subtract line 2l from 1g. Enter the total here.
fi le. The combined penalties, however, cannot exceed
25%.
Line 4a: Enter the number of taxable cigarettes from line
3 and multiply by the rate per cigarette of $0.059. Enter
SPECIFIC INSTRUCTIONS:
the tax due.
ATTACH COPIES OF ALL PURCHASE INVOICES.
Line 4b: Enter the number of cigarettes from line 2i and
Line 1a: Enter the number of packages of 10 cigarettes
multiply by the rate per cigarettes $0.05. Enter the tax
per pack and multiply by 10. Enter the actual number of
due.
cigarettes on line 1a.
Line 5: Add lines 4a and 4b to calculate the total taxable
Line 1b: Enter the number of packages of 12 cigarettes
cigarettes and the total tax due.
per pack and multiply by 12. Enter the actual number of
cigarettes on line 1b.
Line 1c: Enter the number of packages of 16 cigarettes
per pack and multiply by 16. Enter the actual number of
cigarettes on line 1c.
ADOR 11039 (9/13)
Arizona Form 841
Page 4 of 4
Previous 14-2026 (11/02)
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