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In-State Cigarette Distributor
Mail this return to:
Department use only
Form
Quarterly Reconciliation Report
Cigarette Tax
Date received
511
Oregon Department of Revenue
Tax Year 2014
PO Box 14110
Quarter Ending __________________ Due Date __________________
Salem OR 97309-0910
Distributor
Federal employer ID no. (FEIN)
License number
Business ID number (BIN)
Program
Year
Period
Liability
•
•
•
•
•
•
511
14
03
1
-
Street address
City
State
ZIP code
20-pack cigarettes
25-pack cigarettes
Part 1—Cigarette Stock Summary
Number of packs
Number of packs
1. Beginning inventory of unstamped cigarettes (from line 3, previous return) (include those
cigarettes with other states’ stamps affixed)
2. Total cigarettes received from manufacturers (attach Schedule A, form 150-105-053)
3. Subtract ending inventory of unstamped cigarettes (include those cigarettes with other
states’ stamps affixed)
4. Total cigarettes distributed during reporting period
5. Subtract cigarette distribution and prestamped cigarettes
(attach Schedule C, form 150-105-052)
6. Oregon Taxable Distribution
Part 2—Tax Value of Unaffixed Stamps
$1.31 stamps
$1.6375 stamps
7. Beginning inventory tax value of unused stamps (from line 9, previous return)
$
$
8. Tax value of stamps purchased during reporting period
$
$
9. Subtract ending inventory tax value of unused stamps
$
$
10. Total tax value of stamps used during reporting period
$
$
11.
Subtract tax value of stamps cancelled by an agent of the department during reporting period
$
$
(use gross tax value from 150-105-029, Cigarette Tax Refund Certificate)
12. Total tax value of stamps used during reporting period (total tax paid)
$
$
13. Total tax due (line 6 x pack rate $1.31 or $1.6375)
$
$
$
14. Difference: Line 13 minus line 12
$
Under penalties for false swearing, I declare that I have examined this report, including accompanying schedules and statements. To the best of my knowledge and belief, it is true, correct, and complete.
Signature
Title
Telephone number
Date
(
)
X
/
/
150-105-051 (Rev. 12-13)