Příloha č. 4 x xxxxxxxx x. 467/2003 Xx.
Xxxx tiskopisu xxx xxxxxxxx tabákových xxxxxxx
XXXXX
x xxxxxxxxx, xxxxxxx x xxxxxxxxx xxxxxxxxxx xxxxxxxxx xx xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
a) pro xxxxxxxx
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Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx xx xxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxxxxx x cigarillos
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
x) xxx xxxxx xx kouření
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
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Datum xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
2. Xxxxx užití xxxxxxxxxx xxxxxxx xx xxxxxx xx xxxxxxx xxxxx Xxxxx xxxxxxxxx
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Xxxxx vydání Xxxxx Xxxx pro Počet xxxxxxxxxx xxxxxxx x kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, kg) spotřebitele vydaných xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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3. Xxxxx užití xxxxxxxxxx xxxxxxx mimo xxxxxx xxxxx České xxxxxxxxx
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Datum xxxxxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně užitých xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx daňové xxxxx
xxxxxxx Xxxxx xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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4. Xxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxxxx
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Xxxxx Xxxxx Xxxx xxx Xxxxx xxxxxxxxxx xxxxxxx v kusech
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx položek: CELKEM:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx x xxxxxx
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