Příloha č. 4 x xxxxxxxx x. 467/2003 Sb.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx nálepek
XXXXX
x xxxxxxxxx, xxxxxxx x vrácených xxxxxxxxxx xxxxxxxxx xx xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
x) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx xxx xxxxxxxxx Xxxxxxxx
(xx) xxxxxxxxxxxx xx balení
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
x) xxx doutníky x cigarillos
____________________________________________________________________________________________
Xxxxx xxxxxx Xxxxxxxx
(ks)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Datum xxxxxxxx Xxxxx a podpis xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
x) pro tabák xx xxxxxxx
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Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
2. Xxxxx xxxxx xxxxxxxxxx xxxxxxx xx xxxxxx xx daňovém xxxxx Xxxxx republiky
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Xxxxx xxxxxx Xxxxx Xxxx pro Xxxxx xxxxxxxxxx xxxxxxx x xxxxxx
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx xxxxxx xx výroby užitých
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
3. Výkaz xxxxx xxxxxxxxxx xxxxxxx xxxx xxxxxx území České xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Cena xxx Počet xxxxxxxxxx xxxxxxx v xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx užitých xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
cigaret České xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
4. Xxxxx xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx xxxxxxx
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx pro Xxxxx tabákových xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno xxxxxxxx
xx balení
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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Xxxxx: Xxxxxxx x xxxxxx
xxxxxxxxxx