Příloha x. 4 x vyhlášce x. 467/2003 Xx.
Xxxx tiskopisu pro xxxxxxxx xxxxxxxxxx xxxxxxx
XXXXX
x přijatých, xxxxxxx a xxxxxxxxx xxxxxxxxxx xxxxxxxxx na xxxxxxxx xxxxxxx
1. Xxxxx xxxxxxxxx tabákových xxxxxxx
a) pro xxxxxxxx
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Xxxxx xxxxxx Xxxx pro konečného Množství
(xx) xxxxxxxxxxxx xx balení
____________________________________________________________________________________________
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Xxxxx xxxxxxx: CELKEM:
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Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx osoby pověřeného xxxxxxx úřadu:
x) pro xxxxxxxx x xxxxxxxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx x podpis xxxxxx osoby xxxxxxxxxx xxxxxxx xxxxx:
x) pro tabák xx xxxxxxx
____________________________________________________________________________________________
Xxxxx balení Množství
(xx)
____________________________________________________________________________________________
____________________________________________________________________________________________
Xxxxx xxxxxxx: CELKEM:
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx a xxxxxx xxxxxx xxxxx xxxxxxxxxx xxxxxxx xxxxx:
2. Výkaz užití xxxxxxxxxx nálepek ve xxxxxx xx xxxxxxx xxxxx Xxxxx republiky
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Datum xxxxxx Xxxxx Xxxx xxx Počet xxxxxxxxxx xxxxxxx x kusech
xx xxxxxx xxxxxx xxxxxxxxx __________________________________________
(xx, xx) xxxxxxxxxxxx xxxxxxxx xx xxxxxxxx xxxxxxxxxxx
xx balení do xxxxxx xxxxxxx
xxxxxxx
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
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3. Xxxxx xxxxx xxxxxxxxxx xxxxxxx xxxx xxxxxx xxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
Xxxxx xxxxxxxx Xxxxx Cena xxx Xxxxx tabákových xxxxxxx x xxxxxx
xxxxxx xxxxxxxxx ________________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx mimo skutečně xxxxxxx xxxxxxxxxxx
xx xxxxxx xxxxxx xxxxx xxxx xxxxxx xxxxx
xxxxxxx Xxxxx xxxxxxxxx Xxxxx xxxxxxxxx
____________________________________________________________________________________________
____________________________________________________________________________________________
Počet xxxxxxx: XXXXXX:
____________________________________________________________________________________________
4. Výkaz vrácených xxxxxxxxxxx xxxxxxxxxx nálepek
____________________________________________________________________________________________
Xxxxx Xxxxx Xxxx xxx Počet tabákových xxxxxxx v xxxxxx
xxxxxxx xxxxxx xxxxxxxxx __________________________________________
(ks, xx) xxxxxxxxxxxx xxxxxxxxx xxxxxx xxxxxx neuznáno
xx xxxxxx
cigaret
____________________________________________________________________________________________
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Xxxxx xxxxxxx: XXXXXX:
____________________________________________________________________________________________
Xxxxx: Xxxxxxx x xxxxxx
xxxxxxxxxx