Arizona Form 840 - Cigarette Distributor'S Claim For Refund Of Cigarette Taxes Paid Page 2
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1
2AZ FORM 840
GENERAL INSTRUCTIONS:
Lines 2a and 2b, Column C: Multiply the figures in
column A by the corresponding rates in column B. Enter
You must file this form to receive a refund for cigarettes
the amount of tax paid.
taxes paid.
Lines 3a and 3b, Column A: Enter the number of
Prepare this form for each refund. File the original
stamps for packs of 20 that are being returned for
with the Arizona Department of Revenue. Retain a
redemption or spoilage. Enclose stamps or indicia with
copy of the form with all substantiating documentation
this claim.
for at least four years, subject to inspection by the
Department.
Lines 3a and 3b, Column C: Multiply the figures in
column A by the corresponding rates in column B. Enter
You must provide your tobacco license number.
the amount of tax paid.
You must provide your taxpayer identification number
Lines 4a and 4b, Column A: Enter the number of blue
on the form. A taxpayer identification number is either
or red stamps for packs of 25 that are being returned for
your Federal Employer Identification Number (FEIN) or
redemption or spoilage. Enclose stamps or indicia with
your Social Security Number (SSN), if you are a sole
this claim.
proprietor with no employees.
Lines 4a and 4b, Column C: Multiply the figures in
The Licensee or Authorized Agent must sign the form.
column A by the corresponding rates in column B. Enter
the amount of tax paid.
If you pay a preparer to complete the form, the preparer
must sign the form and include his or her identification
Line 5: Add lines 1 through 4 of column C. Enter the
number.
total amount of tax paid here.
SPECIFIC INSTRUCTIONS:
Line 6: Follow the procedures used to determine the
discount when purchasing stamps to determine your
Lines 1a and 1b, Column A: Enter the quantity of
refund discount percentage. If you need assistance,
packages returned to the manufacturers bearing either
contact the Luxury Tax Section at (602) 716-7808.
the blue or red Arizona cigarette tax stamps for packs
of 20. Attach the original affidavit of receipt of stamped
Line 6a: Enter the discount percentage in decimal form.
cigarettes from the manufacturer. If more than one
affidavit, you may combine and use one Arizona Form
Line 6b: Multiply line 5 by line 6a.
840.
Line 7: Subtract line 6b from line 5. Enter the net
Lines 1a and 1b, Column C: Multiply the figures in
refund claimed here.
column A by the corresponding rates in column B. Enter
the amount of tax paid.
Lines 2a and 2b, Column A: Enter the quantity of
packages returned to the manufacturers bearing either
the blue or red Arizona cigarette tax stamps for packs
of 25. Attach the original affidavit of receipt of stamped
cigarettes from the manufacturer.
ADOR 11025 (9/13)
Page 2 of 2
Previous ADOR 14-2012
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