Arizona Form 819nr - Schedule A, A-3, A-4 Page 2

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SCHEDULE A-3

AZ FORM 819NR

Schedule A-3

Sheet ___ of ___

Participating Manufacturer’s Roll-Your-Own Tobacco Sold in Arizona

LEGAL BUSINESS NAME

BUSINESS (OR DBA) NAME

TOBACCO LICENSE NO.

FOR THE MONTH OF

MONTH YYYY

Please see deﬁ nitions and instructions before completing this form. Please provide the following information with respect to all Participating Manufacturer’s roll-your-own tobacco on

which you paid state excise taxes. A list of Participating Manufacturers, and their brands authorized for sale in Arizona, is maintained and updated at the Arizona Attorney General’s

web site,

PARTICIPATING MANUFACTURER’S BRANDS:

(a)

(b)

(c)

(d)

Name and Address of

Quantity

Who the Product was Sold To

Participating Manufacturer’s Name

Brand Family

in Ounces

TOTAL ........................................................................................................................................................................................................................................

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