Xxxxxxx x. 4 k vyhlášce x. 467/2003 Xx.
Xxxx xxxxxxxxx xxx xxxxxxxx xxxxxxxxxx nálepek
XXXXX
o xxxxxxxxx, xxxxxxx x vrácených xxxxxxxxxx xxxxxxxxx na xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx xxxxxxxxxx xxxxxxx
a) xxx xxxxxxxx
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Xxxxx xxxxxx Xxxx xxx konečného Množství
(xx) xxxxxxxxxxxx za balení
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
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Datum xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
x) pro doutníky x xxxxxxxxxx
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Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
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Xxxxx položek: XXXXXX:
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Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx osoby xxxxxxxxxx xxxxxxx úřadu:
x) pro tabák xx xxxxxxx
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Xxxxx xxxxxx Xxxxxxxx
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: CELKEM:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx úřadu:
2. Xxxxx xxxxx xxxxxxxxxx nálepek xx xxxxxx na xxxxxxx xxxxx Xxxxx xxxxxxxxx
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Xxxxx vydání Xxxxx Cena xxx Xxxxx xxxxxxxxxx xxxxxxx x kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx do skutečně poškozených
xx balení do xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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3. Xxxxx užití xxxxxxxxxx xxxxxxx xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Xxxx xxx Xxxxx tabákových xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxx xxxxxxxx xxxxxxx xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
cigaret České republiky České xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx položek: XXXXXX:
____________________________________________________________________________________________
4. Výkaz xxxxxxxxx xxxxxxxxxxx xxxxxxxxxx nálepek
____________________________________________________________________________________________
Datum Xxxxx Xxxx xxx Počet xxxxxxxxxx xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxxx celkem uznáno neuznáno
xx xxxxxx
xxxxxxx
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Xxxxx položek: XXXXXX:
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Xxxxx: Xxxxxxx x podpis
xxxxxxxxxx