Arizona Form 841 - Cigarette Distributor'S Monthly Report Of Cigarettes Received In Packages Other Than Of 20 Or 25 Cigarettes Page 2

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Legal Business Name/DBA Name
Tobacco License No.
Schedule A
Tax-Free Sales of Cigarettes in Packages of Other Than 20 or 25 Cigarettes During The Month
Sold to:
INVOICE
DATE
NO. OF
REGISTRATION NUMBER
NAME
RESERVATION
SHIPPED
DATE
NUMBER
CIGARETTES
Total this sheet ...............................................................................................................................................................
Total all sheets ................................................................................................................................................................
Total this month: Enter here and on page 1, line 2h ......................................................................................................
Schedule B
§42-3251 and §42-3251.01 Sales of Cigarettes in Packages of
Other Than 20 or 25 Cigarettes During The Month
(Sales on the reservations for which $.05 per cigarette was collected.)
Sold to:
INVOICE
DATE
NO. OF
REGISTRATION NUMBER
NAME
RESERVATION
SHIPPED
DATE
NUMBER
CIGARETTES
Total this sheet ...............................................................................................................................................................
Total all sheets ................................................................................................................................................................
Total this month: Enter here and on page 1, line 2i .......................................................................................................
ADOR 11039 (9/13)
Arizona Form 841
Page 2 of 4
Previous 14-2026 (11/02)

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