TPT-1 return is due the 20  daythof the month following 
             TRANSACTION PRIVILEGE, USE, AND 
                                                                                               the reporting period.
             SEVERANCE TAX RETURN (TPT-1)                                                      STATE LICENSE NUMBER:
             Arizona Department of Revenue
             PO BOX 29010 • PHOENIX, AZ  85038-9010                                            TAXPAYER IDENTIFICATION NUMBER:
                       For assistance out-of-state or in the Phoenix area:  (602) 255-3381 or 
                       Statewide, toll free from area codes 520 and 928:  (800) 352-4090        EIN        SSN
                                                                                               PERIOD BEGINNING:                   PERIOD ENDING:
 I.  TAXPAYER INFORMATION                                                                      M M D D Y Y Y Y                     M   M D D Y Y Y Y
       Amended         Multipage                One-Time         Final Return:             DOR USE ONLY                                   LABELED RETURN
         Return               Return             Only Return       (CANCEL LICENSE)
      BUSINESS NAME
                                                                                                                                  Print Form
      C/O

      ADDRESS                                                                                  POSTMARK DATE

      CITY                                       STATE ZIP
                                                                                               RECEIVED DATE

       Address Changed
 II.  TRANSACTION DETAIL  (If more reporting lines are necessary, please attach continuation pages.)
         (A)           (B)    (C)                (D)               (E)                                     (F)           (G)      (H)              (I)         (J) = (F × I)
 LINE  BUSINESS        REGION  BUSINESS                                                                                                            ACCOUNTING  ACCOUNTING 
      DESCRIPTION      CODE   CODE               GROSS AMOUNT DEDUCTION AMOUNT           NET TAXABLE AMOUNT              TAX RATE TOTAL TAX AMOUNT CREDIT RATE CREDIT
1
2
3
4
5
 Subtotal .......................................
 III.  TAX COMPUTATION

      1 Total deductions from Schedule A ...............................................................              1

      2 Total Tax Amount (from column H) ..............................................................               2
      3 State excess tax collected ...........................................................................      + 3
      4 Other excess tax collected ..........................................................................       + 4
      5 Total Tax Liability:  Add lines 2, 3, and 4 ......................................................          = 5
      6 Accounting Credit (from column J) ..............................................................              6
      7 State excess tax accounting credit:  Multiply line 3 by .01 ..........................                      + 7
      8 Total Accounting Credit:  Add lines 6 and 7 .................................................               = 8
      9 Net tax due line:  Subtract line 8 from line 5 ................................................               9
      10 Penalty and interest ..................................................................................... + 10
      11 TPT estimated payments to be used ...........................................................              - 11               AMENDED RETURN ONLY
                                                                                                                                       ORIGINAL REMITTED AMOUNT
      12 Total amount due this period .......................................................................       = 12               $
      13 Additional payment to be applied (for other periods) ...................................                   + 13
                                                                                                                                                   DOR USE
      14 TOTAL AMOUNT REMITTED WITH THIS RETURN ..................................                                  = 14               $
      Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my 
      knowledge and belief, it is true, correct and complete.  Declaration of preparer (other than taxpayer) is based on all information of which preparer has 
      any knowledge.
         ►
        PAID PREPARER’S SIGNATURE (OTHER THAN TAXPAYER)
      ►                                                                                        
       TAXPAYER’S SIGNATURE                                   DATE                            PAID PREPARER’S EIN OR SSN
      ADOR 10872 (2/16)
                                  Please make check payable to Arizona Department of Revenue.

Transaction Privilege, Use, and Severance Tax Return (TPT-1)                          LICENSE NO.   ______________________

                                          Schedule A:  Deduction Detail Information
      The deduction amounts that have been listed on the lines in Section II, Column E must be itemized by category for each Region 
Code and Business Code reported.  The total of the amounts listed in Schedule A must equal the total of the Deduction Amounts listed 
on page 1.  (See page 4 of the TPT-1 Instructions.)
      Deduction Codes for itemizing deductions, with a paraphrased description of the deduction (or exemption), are listed at  
www.azdor.gov.  Some of the codes may be used for more than one business code.  Several additional Deduction Codes, 
as well as the statutory wording and any administrative guidance for each deduction code, are provided on the Department’s 
web site.  The actual text of the statutory deduction, exemption or exclusion is controlling for amounts taken as deductions on  
Form TPT-1.  Schedule A must be completed and attached for deductions to be allowed.  Unsubstantiated or incorrect deductions will 
be disallowed and penalties and interest will apply.

                                                             SCHEDULE A
      Deduction Detail
      (K)             (L)       (M)                          (N)                   (O)
                                DEDUCTION                    DEDUCTION             DESCRIPTION OF 
 LINE REGION CODE BUSINESS CODE CODE                         AMOUNT                DEDUCTION CODE  

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
A Subtotal of Deductions ..............................
B Deduction Totals from Additonal Page(s) ..
C Total Deductions (line A + line B = line C)..
      Total Must Equal Total on Page 1, Section III, line 1
ADOR 10872 (2/16)

Transaction Privilege, Use, and Severance Tax Return (TPT-1)                                              LICENSE NO.   ______________________
TRANSACTION DETAIL (ADDITIONAL TRANSACTIONS)
       (A)              (B)  (C)                (D)          (E)              (F)                 (G)     (H)              (I)         (J) = (F × I)
  LINE BUSINESS         REGION  BUSINESS                                                                                   ACCOUNTING  ACCOUNTING 
       DESCRIPTION      CODE CODE               GROSS AMOUNT DEDUCTION AMOUNT NET TAXABLE AMOUNT TAX RATE TOTAL TAX AMOUNT CREDIT RATE CREDIT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
  Subtotal ....................................                                                   

       ADOR 10872 (2/16)