Příloha x. 4 k vyhlášce x. 467/2003 Xx.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
o xxxxxxxxx, xxxxxxx a xxxxxxxxx xxxxxxxxxx nálepkách xx xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
a) xxx xxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx za xxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx xxxxxxxx x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx pověřeného xxxxxxx úřadu:
x) xxx xxxxx xx xxxxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
2. Výkaz užití xxxxxxxxxx xxxxxxx xx xxxxxx na daňovém xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxx Xxxx xxx Počet xxxxxxxxxx xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx balení do xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
3. Xxxxx xxxxx xxxxxxxxxx nálepek mimo xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Cena xxx Xxxxx xxxxxxxxxx xxxxxxx v kusech
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx balení daňové xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx republiky České xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
4. Výkaz xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx xxx Počet tabákových xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno xxxxxxxx
xx xxxxxx
xxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Datum: Razítko x xxxxxx
xxxxxxxxxx